A violent and manipulative father killed himself and his infant daughter the same day a court allowed him access to her, an inquest has been told.
South Australian Deputy Coroner Ian White opened an inquest on Tuesday into the deaths of nine-month-old Kobi Anastasia Isobel Shepherdson and Henry David Shepherdson, 38, at the Barossa Reservoir's Whispering Wall, northeast of Adelaide, on April 21, 2021.
Counsel assisting Martin Kirby said it was a murder-suicide that had shocked South Australians.
"It's unlikely that this inquest will be able to single out any one interaction, any one system or procedure that was ultimately responsible for Mr Shepherdson and Kobi's deaths," he said.
"Each of the potential failings by themselves, might not have led to this outcome, but in combination, the holes through which Mr Shepherdson slipped, in each case, all lined up to catastrophic results."
Shepherdson had a history of violence, domestic violence, drug and alcohol abuse, and mental health issues.
He met Defence Force member Jenna Hutchins on a dating app late in 2019 and she fell pregnant within a month, Mr Kirby said.
After the couple moved in together, Shepherdson began verbally abusing her.
It worsened and Shepherdson was arrested in December 2020, charged with false imprisonment and threats to kill.
He was remanded in custody and an intervention order banned any contact with Ms Hutchins and their daughter Kobi.
In January 2021, Miss Hutchins started receiving calls from Shepherdson in prison.
"Mr Shepherdson called and spoke with Ms Hutchins 149 times," Mr Kirby said.
"And that's 149 crimes," Mr White commented.
Shepherdson gave Ms Hutchins specific instructions on how to drop the charges.
"Once Your Honour hears these calls, you will be asked to classify them as showing highly manipulative behaviour by Mr Shepherdson towards her, and ultimately that he was successful in his strategy of illegally contacting her and having her do what he wanted," Mr Kirby said.
None of the calls were known to police, prosecutors, or the courts, and Ms Hutchins was vulnerable, distressed and without family support nearby, Mr Kirby said.
In February 2021, she signed a form to have the charges withdrawn.
Shepherdson was released from prison and in March, police found him hiding in Ms Hutchins' bathroom.
He was returned to custody, and a week later, pleaded guilty to two counts of breaching the intervention order and was sentenced to six days in prison.
Ms Hutchins told police she wanted the intervention order to remain. But weeks later, she signed another form to vary conditions so there could be contact.
On April 21, 2021, Shepherdson appeared in Adelaide Magistrates Court and through his lawyer, asked if the intervention order could be varied, Mr Kirby said.
The prosecutor conducted checks on police systems and agreed to remove the non-contact conditions.
On the same day, Shepherdson arranged to spend time with Kobi.
That afternoon, he travelled to the 34m-high Whispering Wall, and with Kobi strapped to his chest in a child carrier, climbed over the railing and jumped.
"From the first report by Ms Hutchins in October 2020, both SA police and Department of Correctional Services were aware and had access to records demonstrating Mr Shepherdson's past history, his history of violence, breaching court orders and his poor mental health," Mr Kirby said.
"I want to emphasise Ms Hutchins was a caring and diligent mother suffering intense mental and sometimes physical abuse from Mr Shepherdson."
The inquest would try to answer many questions, including how Shepherdson was accessing opioids from his GP, Mr Kirby said.
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