South Australia's Department of Child Protection (DCP) did not intervene in the 10 days before an 11-week-old baby died in squalor because one of its regional offices "had no capacity to deal with the notification", an inquest has heard.
WARNING: Readers may find details in this story distressing.
State Coroner David Whittle is investigating whether the unacceptable living conditions contributed to the boy's death in late 2018.
He was found cold and unresponsive while sleeping on a fold-out couch with his then-18-year-old mother, two older siblings and another teenager.
An autopsy found the boy, whose identity is suppressed, died of a respiratory tract infection.
But the inquest heard he could have died from Sudden Unexplained Death in Infants (SUDI) from sleeping in an unsafe environment.
Mr Whittle is also investigating what action DCP took in the lead-up to his death, given there had been 23 notifications made about the boy and his siblings between 2015 and 2018.
Opening the inquest, counsel assisting the coroner Sally Giles told the court the boy died in a house with soiled nappies, food scraps and cat faeces on the floor, vomit on bedding and dead flies and cockroaches in the kitchen.
She said there was no food in the house and mouldy baby bottles contained curdled liquid.
But Ms Giles said experts would give evidence that it was unclear whether his living environment contributed to his death.
"It's abundantly clear that [the boy] was living in squalor," she said.
"This is not an exercise to criticise a teenage mother … but [she] was known to agencies who could have assisted and an agency that could have intervened."
The inquest heard there were multiple notifications made to DCP before the boy was even born in relation to the conditions of the house, and the immaturity of the mother to parent her children.
Ms Giles said DCP referred one notification to a not-for-profit support service in the regional town she lived, and it was assigned to a case worker in July 2018.
She said the case worker made multiple attempts to enter the mother's house to see the children and their living conditions but was repeatedly refused entry.
"She attended the home on October 24, for a scheduled home visit but when [the mother] came to the door, she told [the case worker] she was too ashamed to let her inside because of the mess," she said.
"She continued to make excuses and avoid appointments with [the case worker]."
The inquest heard the case worker wrote a letter to the mother saying her support would cease, and she notified DCP that the mother had been unwilling to engage with the service and no assessment of the house had been made.
"[The case worker] noted that she suspected the children were being neglected in the home environment," Ms Giles said.
"She reported as part of that notification that each of her attempts to enter the home had been unsuccessful."
Supervisor sought to close the matter, inquest hears
Ms Giles said DCP assessed the notification as needing a 10-day response giving them until November 30 to act.
She said the notification required "statutory intervention" given there had been little to no change to the condition of the house, the mother's unwillingness to engage with services and the vulnerable age of the children.
"The supervisor at the [regional DCP] office that took that intake decided the office had no capacity to deal with this notification," Ms Giles told the inquest.
"On the 23rd of November, she moved to close the notification by seeking her manager's approval.
"DCP did not take any active action within that 10-day period and on the 10th day of that notification, [the boy] died."
SA Police investigating officer Detective Brevet Sergeant Kym Mayger told the inquest he believed the children had been living in "disgusting squalor" for months.
He said police could assist DCP with welfare checks, but his agency had no knowledge of the family until after the boy had died.
"There's been no police attendance at all at that address," he told the court.
Following the death, the mother was charged with three counts of failing to provide for her children.
She was spared jail and ordered to be of good behaviour because she had made significant progress to improve her life and care for her two surviving children.
The inquest heard this afternoon that an expert believed the boy died from SUDI relating to his unsafe sleeping environment.
Forensic pathologist Dr Stephen Wells, who conducted the autopsy, told the inquest that it was most likely a combination of both the respiratory tract infection and sleeping environment that contributed to his death.
He said as a pathologist, he could not make a formal finding in relation to external factors such as co-sleeping on a couch.
But he gave evidence that the risk of death increases for an infant if they sleep in an environment as described by the boy's mother.
The inquest continues.
