The Department for Child Protection failed to adequately safeguard three disadvantaged siblings and did not give their family access to a support program before one of the babies died while co-sleeping with her father, a WA Coroner has found.
Dominic Mulligan's findings highlight concerns about the DCP's Goldfields office for the second time in a week after a 20-month-old girl was left with critical injuries while placed in foster care in Kalgoorlie-Boulder.
Mr Mulligan made an open finding on the cause of death of the six-month-old child in June 2008, but raised the risks of co-sleeping and sudden infant death syndrome.
An inquest held this year was told that baby Benfield, her twin sister and her one-year-old sister, of Kalgoorlie, were left without a carer after their mother, who had a history of severe mental illness, was admitted to hospital as an involuntary patient and their father, Shannon Benfield, was jailed.
Police alerted the DCP to the family's situation, but the department did not take the children into State care and instead played a support role for the extended family.
The children were cared for by a relative and went back into the care of their parents after they returned to the community.
At the inquest, the DCP admitted statutory action should have been taken and the Health Department found the department "inappropriately" classified the case.
"While well-intentioned and loving, all three of the deceased's primary care-givers were particularly challenged as they faced the responsibility of raising the deceased and her sisters," Mr Mulligan said in findings, which were handed down in April and provided to _The West Australian _ yesterday.
"While the DCP took little effective action to safeguard the deceased, they had many opportunities to do so."
Mr Mulligan said, importantly, the department did not offer the family a program dealing with the risks of SIDS and co-sleeping. But it could not be said this would have prevented the baby's death.
DCP director-general Terry Murphy said the department had acknowledged that a stronger child protection response should have been adopted in the case.
Mr Murphy said new guidelines for child protection field officers had been adopted since the baby's death and there had also been increased planning with King Edward Memorial Hospital to target pregnant women whose lifestyles posed a risk to children.
Mr Murphy said there had been a big increase in staffing at the DCP's Goldfields office, from 37 to 87 employees.
He said there was no parallel to be drawn between last week's case and the death investigated by the coroner.