An 11-week-old baby tragically died on a fold-out couch surrounded by rubbish, a situation that could have been prevented if child protection services had acted promptly, according to findings from a recent coronial inquest.
Coroner David Whittle conducted a 13-day inquiry into the 2022 death, which occurred in a regional South Australian home in November 2018. The baby was found deceased amidst clutter on the couch, where he had been sleeping alongside four others. Disturbing video evidence revealed the family’s living conditions, including a cot filled with belongings, piles of rubbish, cat feces, soiled nappies, and moldy baby bottles, with an absence of food in the kitchen.
The family had come to the attention of the Department for Child Protection (DCP) on 23 occasions between 2015 and the baby’s death, primarily concerning the unsanitary environment in which the baby and his siblings were raised.
In his findings, Coroner Whittle pointed out that the mother, as the primary caregiver, had failed to ensure a safe sleeping environment for her child. Over several years, she had demonstrated difficulties in meeting her parental duties, repeatedly prompting concerns that were reported to the DCP.
The coroner highlighted a crucial missed opportunity in November 2018 when a notification about the family’s circumstances could have prompted intervention that might have saved the baby’s life. The initial notification had been made six months before the baby’s birth, signaling early concerns about the suitability of the living conditions for an infant.
The cause of the baby’s death was determined to be complex, attributed to an unsafe sleeping environment compounded by a respiratory tract infection. Notably, the mother had encountered authorities during her first pregnancy due to concerns about her living situation, yet subsequent interventions were hindered by staffing shortages within the DCP office.
Coroner Whittle recommended systemic changes, urging the DCP to refrain from closing notifications due to resource constraints and suggesting that closed cases be approved by the DCP’s chief executive. He also proposed amendments to the Children and Young People Safety Act, advocating for mandatory parenting capacity assessments if a parent is convicted of neglect.
The DCP has been approached for comment on the findings.
