A coroner's findings in regards to the death of a five-months-old baby girl are highly critical of the Kununurra branch of the Department for Community Development (DCD).
State Coroner Alastair Hope handed down his findings in Perth on Friday.
Baby Sturt (name not used for cultural reasons) died on a filthy mattress between her drunken parents in July 2005.
She was the fifth child for Elizabeth Carlton and just the latest to be the subject of complaints of neglect.
Mr Hope said: "This was one of the saddest cases to come before the Coroner's Court, because it appeared that the baby had died in circumstances of extreme neglect."
The cause of death of the baby was pneumonia (haemophilus influenzae superimposed on adenoviral infection).
"A particularly concerning feature of this death is the fact that on May 6, 2005 members of the extended family of the deceased took her to the Department for Community Development (DCD) office at Kununurra and asked representatives of the department to intervene to save the baby.
"They reported that they had been caring for the deceased because her parents were "...out drinking every day.
"It appears that DCD did not actively intervene and that by May 9, 2005 the mother of the deceased had taken the deceased back from family members.
"The deceased and her mother were not seen by departmental staff from that time until the time of the death on July 2, 2005."
Mr Hope said that the doctor performing the autopsy Dr Margolius was a practitioner with very considerable relevant experience and he had never seen such a bad case of severe rashes and apparent neglect.
Nappy rash had been allowed to become so severe that it had caused ulceration of the skin in the anal area and stripping or peeling off of skin in the genital region.
"It appears clear from the post mortem evidence that the deceased died from neglect and that had she been provided with a reasonable standard of care she almost certainly would not have died when she did," Mr Hope said.
And...the baby's mother was no stranger to the DCD - from 1994 until 1998 there were at least eight contacts with the department from significant people who stated that they had concerns regarding Ms Carlton's binge drinking and inadequate arrangements made by her for children.
According to DCD Case Notes on February 5, 1998 Aboriginal district officer Ruth Abdullah concluded that she could not see any need for the department to be involved further as the family was "...perfectly capable of working this out amongst themselves and are already doing this."
Further complaints to the DCD came from Dr Alice Tippetts in December 2000 and from Dr Melisa Cheah in March 2004.
Senior field officer Justine De Candia prepared a case note in which she noted
"SFO [herself] expressed concerns that Dr Cheah may not be aware of the cultural and social issues impacting on these families, given that she is new to the area, and thus may benefit from some discussion around appropriate intervention strategies".
On May 6, 2005 Mary-Ann Stewart (aunt), Ronnie Yunden (uncle), Gracie Mulligan (aunt) and Anita Sturt (aunt) went to the DCD Kununurra office with the baby advising that her parents were out drinking every day and that because this was a regular occurrence they could no longer care for her.
They begged for the DCD to intervene but were told it would be more appropriate for them to take the baby from its mother and lodge it with an aunt in Fitzroy Crossing (in other words kidnap the child).
Mr Hope said: "In my view DCD's handling of the case, particularly after the meeting of May 6, 2005 with family members, was seriously deficient.
The case was allocated, first, to an unpaid student and a field worker who was never advised that the case had been allocated to her, and then was transferred to a new employee who had not yet received the training provided by the department to new workers.
On August 30, 2005 Det. Sgt Tim Lines forwarded an email request to Justine De Candia seeking information as to the identity of staff involved in the deceased's case and advising that he wished to interview them concerning the death.
Ms De Candia never replied to request and subsequently when the department's file was obtained, he discovered that Ms De Candia had instructed staff not to cooperate with police.
Mr Hope acknowledged that there was already 'a difficult working relationship' between the detective and the DCD officer following an incident when police had become aware of the fact that a three-year-old child living at Crocodile
Hole had been infected with gonorrhoea and chlamydia (i.e. had been sexually assaulted) and believed the child to be in peril of further sexual abuse and raised their concerns with DCD because her safety could not be guaranteed in the community but DCD had declined to act, following which the child was again infected with chlamydia (i.e. was sexually assaulted again).
Det. Sgt Lines concluded after his review of the evidence which he had obtained that: "Whilst the death of [Baby Sturt] was not suspicious in itself, I believe that she would have been alive today, if the Department for Community Development had acted, eight weeks prior to her death.
"The Department for Community Development had in their possession, 10 years of case notes with their dealings with Elizabeth Carlton and her failure to care for her children due to her alcoholism."
Mr Hope said: "It is difficult to understand why the group home carer could not have taken the baby into the home, at least overnight.
"I recommend that DCD review the criteria for the provision of emergency care at the group homes or otherwise take steps to ensure that there can be immediate care provided to small babies left by alcoholic parents in situations where appropriate care is not otherwise immediately available.
"I recommend that DCD review the approach taken by its officers in cases where Aboriginal children are at risk of harm in order to ensure that the legislative provisions which require that the interests of the child be paramount are in fact applied, not merely given lip service, and that reliance only be placed on extended family members providing protection to children when there are identified family members who are able and willing to provide such protection.
"There is no doubt that Aboriginal children and babies in the East Kimberley region will continue to be at unacceptable risk of harm while they continue to live in filthy overcrowded homes surrounded by persons who regularly abuse alcohol to excess.
"I recommend that the State Government review the provision of alcohol rehabilitation services within the Kimberley region and particularly give consideration to the setting up of an alcohol rehabilitation centre in the Kununurra area.
"It would appear on the basis of a media statement released by the Premier dated March 7, 2007, that a number of the issues raised in this case have been addressed and that there has been a significant injection of funds into improving child protection in WA," Mr Hope said.
The coroner said he had also been advised that the capacity and staffing levels at the Kununurra Group Home were being reviewed as part of a larger review of country hostels and group homes.