Department for Child Protection staff covering a vast region of South Australia had been directed to close all non-urgent notifications without investigation during the time when a baby living in severe squalor died, an inquest has heard.
WARNING: Readers may find details in this story distressing.
State Coroner David Whittle is investigating whether the unhygienic state of a regional home contributed to the death of an 11-week-old baby boy in November 2018.
Mr Whittle is also examining the Department for Child Protection (DCP) response to the 23 notifications received about the family between 2015 and his death.
The boy was found unresponsive while sleeping on a filthy, fold-out couch with four others, including his two older siblings.
Video footage played to the inquest shows the house was covered in rubbish, cat faeces and soiled nappies, with no food in the kitchen and mouldy baby bottles.
The inquest has previously heard that DCP's Child Abuse Report Line (CARL) would give child protection notifications either a 24-hour or 10-day response time before being forwarded to an South Australian office for investigation.
On November 20, 2018, the final notification received about the boy living in squalor was sent to the regional office with a 10-day response.
It was closed, without action, three days later.
In court on Friday, Dianne Longman told the inquest she was one of three supervisors working in the regional DCP office in the town where the family lived.
She said each supervisor had responsibility for a team covering three areas: notification intake, preventative intervention and guardianship.
However, she said, by January 2018, the two other supervisors had left, and she was the "sole supervisor" responsible for all three teams and DCP had failed to fill the two vacancies when multiple notifications about the boy were sent to her office.
Ms Longman told the inquest that another regional DCP outpost was tasked with assessing some of her office's notifications "because it was just myself trying to manage the whole office".
However, she said, her manager later directed her to close all notifications given a 10-day response by CARL without any action.
"We only responded to 24-hour responses," she told the inquest.
Counsel for Ms Longman asked her whether she ever "disregarded" the direction to close all 10-day notifications without action.
She responded: "Yes, I did."
Ms Longman said the final notification on November 20 was closed by the other regional DCP office tasked with helping her, and she found the decision "surprising".
Her lawyer asked her why it was surprising that the other office moved to close the notification without action.
"The difference would be the lack of engagement from the mother with services," she said.
In responding to a question about what she would have done differently, she replied: "I would have allocated it to a case worker."
The inquest was told Ms Longman was the sole supervisor at the DCP office from January 2018 until January 2019, when another supervisor was successfully recruited.
Ms Longman told the inquest that the direction to close non-urgent notifications changed at some point, but she could not recall when.
Mother 'overwhelmed' by DCP involvement, supervisor says
Ms Longman was asked whether DCP ever spoke her after the death of the baby boy, as part of a review or debriefing into the handling of the case.
However, Ms Longman responded that SA Police was the first authority to seek any information about her office's response to notifications regarding the boy and squalor at the house.
The inquest was told Ms Longman had one brief interaction with the mother of the boy, in May 2018, when she inspected the house.
"When we were at the house, she was just very heightened to us being there," she said.
She said the mother was "overwhelmed" by DCP involvement but was positive about being assigned a case manager from an external support service.
The court heard DCP ordered a skip bin so the mother could clear some clutter and was given a card to purchase some cleaning products.
Ms Longman told the inquest her next interaction with the mother occurred on the day her son died.
The inquest continues.
