A coronial inquest into the death of a baby who died in squalor has heard it was a "horrible reality" that the state's child protection workers "more often than not" had to close abuse notifications without investigation — against the law — due to chronic understaffing.
WARNING: This story contains graphic details
The 11-week-old baby boy, who cannot be identified, died in regional South Australia in November 2018. He was found unresponsive while sleeping on a filthy, fold-out couch with four others.
The inquest has heard the infant 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.
There was no food in the house and mouldy baby bottles contained curdled liquid.
The baby and his older siblings had been the subject of 23 notifications to the Department for Child Protection (DCP).
About 10 days before the baby's death, a notification was made about the family to DCP's Child Abuse Report Line (CARL) which required a 10-day response.
That notification was made after the baby's mother either cancelled or did not show up for 13 out of 15 scheduled appointments with a community service provider to improve her parenting.
CARL notifications are given either a 24-hour or 10-day response time frame.
The notification about the baby and his siblings was closed without action three days later.
'No choice' but to close reports
Patrick Kinnear, who was the manager of the DCP office at the time, said they "had no choice" but to close all 10-day notifications at the time without investigation or review.
He told the inquest the regional office, which required three supervisors, only had one for 14 months, combined with "quite a number" of staff vacancies, which curbed its ability to carry our its role as required under the legislation.
"There was agreement amongst the leadership team … that due to the chronic continued understaffing there would only be capacity to action the most urgent, pressing matters," he said.
"Therefore, 10-day responses would be closed.
"That was the horrible reality we were faced with.
"We were in a very challenging situation and we only had limited capacity to do the work that we were meant to be doing under legislation."
But Mr Kinnear told the inquest "more often than not" 10-day notifications would be closed without review to manage staff workloads.
He could not recall whether he told the regional DCP director that his team was closing notifications without investigation against DCP policy.
Mr Kinnear said he had made it clear that understaffing was a major problem and some short-term support was put in place, including bringing staff from Adelaide offices to the region to assist with investigations.
"But it was quite limited due to limited capacity across the organisation," he said.
He said DCP understaffing was a state-wide issue and even offices that were not understaffed were "abusing" the response time frames.
"I do know some of the metropolitan offices would have allocation meetings and my understanding was they were based on not being able to assess even their urgent matters," Mr Kinnear told the inquest.
