The deaths of two South Australian children, murdered by their mother's partner, have been ruled preventable with a coroner chiding authorities over the handling of the family's case.
In findings handed down on Thursday, Deputy State Coroner Anthony Schapel said Korey Lee Mitchell, five, and his six-year-old sister Amber Rose Rigney had lived within a "milieu of dysfunction, neglect and occasional violence".
He criticised child protection officials for failing to properly investigate multiple reports of potential abuse and inadequate care with the repetition of those reports lending much weight to the information being provided.
At the very least, a more vigorous investigation of the family should have been conducted by Families SA.
"Even if the children were not removed from the custody of their mother, a departmental investigation would have revealed the completely unsatisfactory nature of the manner in which the two children were being cared for," Mr Schapel said.
"This family required extremely close scrutiny and supervision.
"The mother's amphetamine usage should have been the subject of an examination and have been curtailed.
"To my mind, the police should have been asked to investigate these allegations."
Steven Graham Peet is serving a 36-year non-parole period after pleading guilty to killing both children and their mother, Adeline Yvette Wilson-Rigney, in May 2016.
He was not the father of the children but was living with them and their mother at the time.
Mr Schapel said that for a significant period leading up to their murders, Amber and Korey lived in an environment that was on any objective analysis dysfunctional.
He said this was known to authorities who, when it was too late, attempted to do something about it.
"While nothing was previously known about Peet to suggest that Ms Rigney or the children had been at risk of harm from him in particular, it was in this milieu of dysfunction, neglect and occasional violence that the children met their deaths," the coroner said.
"Needless to say, responsibility for these callous murders lies with Peet.
"This inquest was undertaken to ascertain whether or not the deaths could have been prevented by the child protection authorities assuming a more vigorous role in relation to the protection of the two children.
"The answer to this question is that their deaths could and should have been prevented."
In his recommendations, Mr Schapel raised the issue of resourcing which was alleged to have impacted the department's failures.
"It is manifest that such a situation should never be allowed to develop and be tolerated ever again," he said.
The coroner also recommended the state government conduct a complete review to ensure Families SA was meeting all its statutory obligations for the safety of children.
In response, Premier Peter Malinauskas said the government would closely analyse the coroner's recommendations and ensure an adequate response was put in place.
"The murders were an absolute tragedy. We're talking about the loss of a parent and children in a way that shocked a lot of South Australians at the time," he said.
"Government can never replicate the love of a parent or a guardian.
"What we can do is our level best to ensure that we are constantly improving the culture within the child protection department, the resources they have and the quality of skills they have at their disposal to ensure that these sort of tragedies are averted."
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