The death of an 11-week-old boy in a squalid home could have been prevented if the Department for Child Protection had acted on multiple reports he and his siblings were at risk, the SA coroner has found.
Delivering findings on the death of the infant known under the pseudonym "Caleb Evans" in 2018, State Coroner David Whittle said the cause of his death was "'unascertained, in an unsafe sleeping environment on a background of respiratory tract infection".
The boy lived in squalor "likely for the entirety of his short life".
Caleb's mother "Angela Evans" was 14 when she became pregnant with her first child "Dawn", who was born in 2015. Her second child "Eva" was born in 2017 and Caleb was born in September 2018.
Ms Evans told police on November 29, 2018, she was on a foldout sofa in her lounge room and went to sleep while cuddling Caleb. She woke to find him cold and unresponsive and he could not be revived.
The Department for Child Protection had been involved with Ms Evans since the birth of her first child. There were 23 reports about risks to the three children, including at least five reports in 2018.
Following Caleb's death, Ms Evans pleaded guilty to three counts of failure to provide necessary food, clothing and accommodation for her children.
"There were opportunities for DCP to have intervened in a manner which would have prevented baby Caleb from living and sleeping in the environment he was in," Mr Whittle found.
"Had baby Caleb been removed, he would have been sleeping in a clean, well set up cot, rather than in an unsafe sleeping environment and this may have prevented his death."
Police found faeces on the floors, rotten food in the cockroach-infested pantry, baby bottles containing putrid liquid and the smell of urine, faeces and rotting food permeated the house.
The first notification involving Caleb was on March 14, 2018.
The notifier said the family was living in squalor. It was "closed no action" by DCP on March 19, 2018, due to a lack of capacity to allocate the case.
"This was the first time DCP was notified that baby Caleb was to be born to a mother who was living in troubling circumstances that were unlikely to be suitable for a young infant," Mr Whittle wrote.
He found it was "a significant missed opportunity for DCP to intervene".
A child abuse notification on November 20, 2018 "should have raised alarm bells" that Ms Evans' children were again living in squalor.
"It is an inescapable fact that the inability of DCP to properly staff the Port Pirie office for an extended duration of time had dire consequences for baby Caleb," Mr Whittle found.
He said in the years between Caleb's death and the inquest in 2022 "DCP made significant changes to its practice".
Mr Whittle noted recommendation 62 of the 2016 Child Protection Systems Royal Commission Report was to phase out the closure of reports due to lack of resources, but this had not been fully implemented.
His recommendations included that nine months on from the delivery of his findings, no reports are to be closed due to lack of resources without the approval of the DCP chief executive and recommendation 62 should be fully implemented within 18 months.
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