Inquest into 11-week-old baby who died in squalor hears child protection supervisor was told not to investigate welfare reports

Child Protection workers shelved a report about an unborn baby at risk – and again when the new-born was found in squalor – before the 11-week old died, an inquest has heard.

Welfare reports about a baby – even when he was not yet born – were shelved because of workload pressure in the Department for Child Protection.

An inquest into the infant’s death has been told a regional manager ordered staff to close child welfare notifications listed for action within 10 days due to a staff shortage and instead focus on those needing attention within 24 hours.

Former regional supervisor Dianne Longman told the inquest her manager Patrick Kinnear issued the order after their office lost two supervisors in December 2017, leaving her juggling three senior roles.

She could not recall if the order had been rescinded and was not aware of it applying to other areas.

The inquest into the death of the 11-week old baby on November 30, 2018, heard a welfare notification was made on November 20, but as it was assessed as needing action within 10 days it was closed with no action on November 23.

The home in which the baby lived and died – he was sleeping on a fold-out couch with his mother and other children when he was likely crushed to death. Picture: SA Police

A report on September 14, 2018, to the department call centre about the same family warning of child abuse and “an unborn baby concern” was not passed on to the regional office and was closed with no action.

The identity of the family has been suppressed.

Ms Longman said she believed the order was a temporary management step and on occasion, she ignored it and began investigations.

Asked by Coroner David Whittle if she “contravened the direction on her own initiative,” she said “yes.”

Ms Longman said the directive ordered cases requiring action within 10 days “be closed, no action, it depends on the assessment but the majority of those were closed due to the high workload”.

Ms Longman left the department in January 2021.

She told the inquest her only direct involvement with the family was a visit on May 3, 2018, after notifications the family was living in squalor including animals faeces throughout the house.

She arranged a skip bin for a rubbish clean-up and the purchase of cleaning products.

Three follow-up visits in May and June by other welfare workers found the situation had improved and the file was closed on July 9.

However on September 14, 2018, the call centre received a child abuse report about “an unborn child concern”, which effectively was ignored and the matter “closed with no action”.

Ms Longman said another welfare alert about the family arrived on November 20, 2018, with a 10-day window for action.

The family was living in squalor, police say, with animal faeces in the house. Picture: SA Police

She disputed a police statement taken almost a year after the death that recorded her saying there had been a review and “our office didn’t have the capacity to intervene and the matter was closed with no further action”.

She told the inquest another regional staff member, Jane Hutchison, “reviewed it and ticked the box as ‘close, no action’.”

Despite the order to close such cases with no action, Ms Longman told the inquest it was a “surprising” decision due to the family’s known circumstances.

“I would have opened the notification to a case worker,” she said.

After the baby’s death just days later Ms Longman said she was not debriefed by departmental officials nor involved in any review.

She was told by SAPOL the baby died of SIDS and subsequently made a statement it “was not due to child protection concerns.”

However, she told the inquest in hindsight “the death may have been contributed to by child protection neglect”.

She visited the home just over a week after the baby’s death and stated: “If the air conditioner had not been on we would not have been able to enter the property due to the foul smell.”

The family had been the subject of 23 welfare notifications.

Major Crime detectives were called in to investigate unexplained injuries on the child police thought was the result of him being crushed while co-sleeping with his mother, siblings and an unrelated teenager.

After the death, police found the property strewn with rotten food, animal faeces and vomit-covered beds.

The inquest continues.