Coroner's Finding: Evans, Caleb

Contributing factors

• unsafe sleeping environment - co-sleeping on fold-out sofa with mother
• inadequate DCP response to notifications
• failure to action screened-in notification of 20 November 2018
• squalid home environment with poor hygiene
• maternal inability to maintain safe home
• chronic understaffing in DCP Port Pirie office
• closure of notifications without action due to resource constraints
• absence of parenting capacity assessment
• lack of CaFHS engagement due to maternal opt-out
• respiratory tract infection (rhinovirus pneumonia)
• maternal smoking
• gaps in sofa design creating asphyxiation risk
• loose blanket creating entanglement risk

Coroner's recommendations

1. That the CYPSA be amended to require a court which finds a parent of a child guilty of an offence against Section 14A of the CLCA to notify both DCP and CaFHS.
2. That the CYPSA be amended to require the Minister or Chief Executive of DCP to apply to the Youth Court for an order that a parenting capacity assessment be undertaken when a parent who still has a child or children in their care has been found guilty of an offence against Section 14A of the CLCA.
3. That a policy or protocol be developed providing for CaFHS to notify DCP when a parent with a known child protection history opts out of CaFHS involvement with a new infant.
4. That a policy or protocol be developed providing for Unborn Child Concern notifications to be shared by DCP with CaFHS.
5. That the phasing out of the closure of intakes and files due to lack of resources, as recommended in Recommendation 62 of The Life They Deserve, be completed within 18 months of the date of this finding.
6. That after nine months from the date of this finding, no intake be closed due to lack of resources without the specific approval in writing of the Chief Executive of the Department for Child Protection.
7. That a policy be developed which identifies the circumstances in which a notifier is to be advised, or not advised, that a notification has been closed with no action (if Recommendation 40 of The Life They Deserve is not to be implemented).