The 11-week-old baby was found dead on the couch at his regional SA home in November 2018.The inquest heard the family had been the subject of 23 notifications to child protection authorities.
The family had been the subject of 23 notifications to the Department for Child Protection between 2015 and the baby's death. "However, the baby's mother had consistently demonstrated over a number of years that she struggled to meet her parenting responsibilities.The coroner found if DCP had responded to the November 2018 notification, the baby would have been removed from the home and not sleeping on the couch.
He found the cause to be "unascertained", but said the death occurred "in an unsafe sleeping environment, on a background of respiratory tract infection".