Four more dead babies revealed in Department of Child Protection report but Premier was unaware

Premier Peter Malinauskas was unaware of the deaths of four babies known to the Child Protection Department, which were only revealed in a report kept secret for four years.

Premier Peter Malinauskas says he was unaware of the deaths of four babies known to the Child Protection Department and has described details of their short lives as “heartbreak on top of heartbreak”.

The deaths only became public when an internal department report was provided to the Coroner’s Court as part of an inquest into the death of an 11-week-old boy who died in November, 2018, while living in squalid conditions with his teen mother and young siblings.

The tragic lives and deaths of the four other babies were recorded in an Adverse Events Review Report done in August 2018.

It makes clear that concerns raised about their welfare while their mothers were pregnant were not prioritised because the department was so stretched focusing on children who were already born.

The babies’ cases involved concerns including about mental health, domestic and family violence, substance misuse or criminal history.

“It strikes me as heartbreak on top of heartbreak,” Mr Malinauskas said when asked about the cases.

Premier Peter Malinauskas, flanked by Child Protection Minister Katrine Hildyard. Picture: NCA NewsWire / Brenton Edwards

“To say that it’s frustrating is probably a bit of an understatement.

“All of what we’re learning about ... is newsworthy and news to us.

“Most of these incidents that we’re now learning about go back to a period some time ago, but nonetheless this is something that I am examining on a frequent basis.”

Asked if he had confidence in the department’s chief executive Cathy Taylor, Mr Malinauskas said: “We very much see that there is a need for improvement in the Department of Child Protection. Cathy Taylor is aware of my expectations and that’s something that I monitor very closely.”

The departmental review – revealed exclusively by The Advertiser on Friday – found it was common that reports made about the welfare of pregnant women and their babies, known as Unborn Child Concerns (UCC), “were not allocated” to a worker.

Reports about those babies after they were born were also often closed without the department taking action.

“The information reviewed indicated that in most cases, pre birth assessment and planning was not undertaken by the DCP because cases/intakes relating to born children were prioritised to ensure the safety and wellbeing of those children,” the review states.

The department said in the review it did not directly cause any of the deaths but says it has since updated its policies on responding to concerns about unborn children and infants at risk.

The Advertiser has put questions about the review to Child Protection Minister Katrine Hildyard.

The department successfully argued for a suppression order on the identity of the baby subject to the coronial inquest, which is examining the department’s interactions with that boy’s family. The other four babies who died cannot be identified for legal reasons.

One of the babies’ parents was a child themselves.

Nine out of ten reports about the babies were closed without any action.

The one outlying notification was allocated to a worker but was closed before the baby was born, the review notes.

Baby girl CB was born on March 5, 2017, and died at seven weeks of age while feeding, blood oozing from the infant’s nose. A cause of her death has not been found.

A report about the baby before her birth was raised in January 2017 because of the mother’s methamphetamine use, a lack of antenatal care and her mental health.

The Kadina DCP office closed the case and a flurry of subsequent reports and even though one report stayed open there was no case work deployed to help the girl.

There were just 2.6 full time workers in the Kadina DCP office at the time and the case workers were overloaded.

Baby CW was born on December 27, 2016.

Child protection workers in NSW raised an all states alert in October because the mother had recently left state care, was the victim of domestic violence, had diminished cognitive capacity and used drugs.

The father was a domestic abuser who had warrants for his arrest and his other children had been removed from his care.

A concern report was lodged in November because the parents were living in a car but the Elizabeth DCP office closed the case without action.

Another similar report to the first two came in December and was again closed by the Elizabeth DCP report.

The review found there were no issues related to DCP staff performance, even though workers did not notify SA Police given the father was wanted on warrants.

Baby WS was born on March 5, 2018 and died at just two hours old of a bacterial intra-amniotic infection after the mother suffered a ruptured membrane prior to an emergency caesarean.

The baby’s mother was in state care as a child herself.

On Boxing Day, 2017 a report was raised because the mother was heavily intoxicated and had been the victim of domestic violence. The Port Augusta DCP office closed the report the next day.

By February the mother had been stabbed in the stomach with a screwdriver by the baby’s father and while DCP finally decided to take action, they did not make any intervention before the baby was born gravely ill.

“The Port August DCP office recorded that the delay in allocation was due to staff shortage,” the review found.

Again, the internal review found no issue with staff performance.

In another tragic outcome, baby MP was stillborn on June 18, 2015 after nine people came forward over five months reporting concerns.

The father was a child under guardianship of the minister. The mother was using substances while pregnant, had mental health issues and had been the victim of domestic violence.

In May 2015, there had been a family meeting involving the parents but the case was closed after consultation with a social worker.

The review found at the time the concerns were raised “staffing was an issue at the Whyalla DCP office and the office was under resourced.”

In another case, concerns were raised about a baby whose mother “inflicted serious injuries”, including bites, but reports were closed without action. The child survived but by the time action was taken she had a healing fracture in her left thigh bone.