A NSW government agency failed to offer adequate support to a mother struggling with drug addiction before the sudden death of two babies, a coroner has found.
The inquest held earlier this year at Glebe Coroners Court examined the sudden deaths of two half-sisters, known as BLGN and DG, who were three months and 19 days old respectively when they died in 2014 and 2015.
In her findings, Deputy State Coroner Harriet Grahame said there were "significant" failures in the level and nature of support offered to their mother by the Department of Family and Community Services.
"As (the mother) struggled to parent with a serious ice addiction, FACS failed to offer her useful support or appropriate intervention," Ms Grahame said.
While the cause of death for each of the children was undetermined, the inquest found there was a bureaucratic failure and "ongoing inadequate" response to a family in genuine need.
The coroner was able to rule out the possibility that BLGN's death was suspicious, noting there were factors which suggested unsafe sleeping practices but she couldn't say if they were responsible for the infant's death.
The inquest also found the culture at the local FACS community service centre was one where workers accepted most matters could never be allocated to resources.
"The picture that emerged of the local CSC was one of overwhelming hopelessness," the report said.
In her findings, Ms Grahame said it was "reassuring" FACS recognised the systemic and ongoing issues in relation to the allocation of cases.
Some of the changes already undertaken by FACS include improved training, increased number of caseworkers, better data collection and a greater focus on the performance of community service centres.
In handing down the recommendations, Ms Grahame said: "The problem is clear and urgent. We are currently failing children who need our help."
FACS has been asked to undertake a review of its resource allocation, examine the performance of each district and amend its policies regarding assessments, reports and resource allocation.
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