State Coroner finds 11-week-old baby’s death was ‘preventable’ if DCP had intervened
An infant boy who spent his final night sleeping on a fold-out couch in a “squalid” home would still be alive if DCP had intervened, according to the State Coroner.
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The death of an 11-week-old baby boy who spent his final night sleeping on a fold-out couch in a “squalid” home could have been prevented if the Department for Child Protection had intervened at the right time, the State Coroner has found.
After an inquest into the death of the infant, known as “Caleb Evans”, State Coroner David Whittle on Friday handed down his findings, and said he “disagreed” with submissions put forward by the Department for Child Protection that there was nothing they could do to save the baby.
Baby Caleb died in November 2018 while co-sleeping with his mother and young siblings on a fold-out couch in a house heavily littered with rubbish and faeces.
DCP had reportedly been notified of risks to the baby and his siblings 23 times, with many of the reports made before the baby boy was even born.
The last time DCP was notified about concerns for the infant was on November 20, 2018 – just ten days before his death.
In December 2022, the inquest at the Coroner’s Court was shown footage and photographs of the conditions the baby was living in before his death on November 30, 2018.
The photographs show the house covered in rubbish, with items strewn across floors and on surfaces.
In the video footage, a detective is heard commenting on the scent of the home: “There is quite a bad smell of animal faeces through the house.”
Following the boy’s death, his mother pleaded guilty to three counts of failure to provide necessary food, clothing and accommodation to the infant and his two siblings.
“One of the matters considered upon inquest was whether baby Caleb’s death may have been prevented. That including considering whether, had DCP acted differently in response to any of the notifications it received in relation to baby Caleb, his death may have been prevented,” Mr Whittle said in his findings on Friday.
He reiterated the evidence given by pediatrician Associate Professor Dr Michael Starr during the inquest, who said that if Caleb had been put to bed in a cot “like any other baby, without anything in the cot” and if “the mother didn’t smoke” while she was “co-sleeping” with the child, “then this death would not have happened”.
“They’re all preventable things,” Dr Starr said during the inquest.
Mr Whittle found it was up to Caleb’s mother as his “primary caregiver” to ensure he was looked after, but she had “consistently demonstrated” over the years that she had struggled to meet her parenting responsibilities.
However, he said that despite multiple complaints to DCP and opportunities for intervention, the department failed to act appropriately.
“Concerns about the way in which she parented were frequently brought to the attention of the DCP,” he said.
“DCP submitted that the evidence supports a finding that DCP could not have prevented baby Caleb’s death; nor had DCP caused or contributed to the death. I disagree.
“It is clear that there were opportunities for DCP to have intervened in a manner which would have prevented baby Caleb from living and sleeping in the environment he was in at the time of his death.
“It was accepted on behalf of DCP that it is reasonable to conclude that, if DCP had taken action in response to the notification of 20 November 2018, rather than closing it with no action, then baby Caleb would have been removed from that squalid home environment.
“Had baby Caleb been removed from that environment, he would have been sleeping in a clean, well set up cot, rather than in an unsafe sleeping environment, and this may have prevented his death.”
Mr Whittle said that in the years between Caleb’s death, and the inquest taking place in 2022, “DCP made significant changes to its practice”.
“If baby Caleb’s case was dealt with by DCP today, the response would have been different and likely have resulted in better engagement with (his mother).”
Minister for Child Protection Katrine Hildyard said on Friday afternoon that the department will “be very carefully and closely examining the findings”.
“It speaks to the need for the department to have done things better at the time of this tragic incident. Things needed to change and we have set about making changes,” she said.
“A few years ago, the rate of ‘no action’ cases sat at around 55 per cent. That number is now reduced to 18 per cent and we are continuing to investigate more cases.
“It’s devastating to read and we will look at the issue about notification and improving responses to notifications.”
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