South Australia's Deputy Coroner has recommended a national database for child protection cases after an inquest into the death of baby Ebony.
The four-month-old died in November 2011 of horrific injuries at the hands of her father, who is currently in jail.
She was left dead in her cot for a week at her teenage parents' Brooklyn Park unit in Adelaide's west before they alerted Families SA.
Deputy Coroner Anthony Schapel, who handed down his summary of the findings, said the girl's death could have been prevented if Families SA staff and South Australia Police had handled the case better.
The inquest heard the couple had moved from New South Wales when the mother was pregnant.
The mother, who was 17 when baby Ebony was born, was under the guardianship of the NSW Government.
The father's history with the NSW Department of Community Services included allegations that he had assaulted two other children and abused cannabis.
Mr Schapel said Families SA's failure to request information about the father's background from NSW authorities was "an egregious oversight".
"The incompetence being all the more culpable having regard to the relative ease with which the information about [the father] could have been obtained," he said.
Mr Schapel said a national child protection database would ensure immediate access to interstate records.
He also recommended sending out an alert when contact is lost with a child's parents.
"In so far as it is necessary, legislation should be introduced to facilitate such nationwide access to child protection information in order to overcome any privacy considerations," Mr Schapel said.
Ebony's leg broken after she was dropped by 'stoned' father
Mr Schapel said Families SA should have taken a keener interest in the girl's care and protection and a more thorough police investigation was needed after the girl's leg was broken prior to her death.
The inquest heard how the father told Families SA he accidentally dropped the girl and her leg became caught between the wheels of her pram.
The father admitted to Families SA he earlier smoked a bong and it may have "slowed him down a bit" and he "needed to get off the dope".
Mr Schapel said the explanation was "intrinsically flawed", the investigation "lacked enthusiasm" and Families SA had "erroneously" cleared the father.
"This lack of cohesion and failure to address all essential requirements of an investigation such as this was due in part to [Families SA supervisor Loretta Parenta] Ms Parenta's lack of appetite for the task," he said.
On anyone's version of events, [the father] had caused the injury and had done so under the influence of cannabis," he said.
"Thus it is difficult to see how it could be said that the parents had been cleared of having caused the injury."
Ms Parenta blamed workload issues for closing the file and for not further investigating baby Ebony's case.
Mr Schapel it was hard for the court to judge the validity of her claim.
He acknowledged Ms Parenta's claim that she did not have the capacity to allocate the file after another worker left the office and admitted her claim could not be completely ruled out.
"I do observe that Ms Parenta did not mention in her closure note any such difficulty as being a reason for closing the file," Mr Schapel said.
He recommended changes to ensure case files were only closed by authorities higher than Families SA supervisors.
Deputy Coroner draws from Chloe Valentine recommendations
Mr Schapel further referred to the coronial inquiry into the death of four-year-old Chloe Valentine, who died from horrific injuries she sustained while being forced repeatedly to ride a motorbike at her Ingle Farm home in Adelaide's north in January 2012.
"It is also surprising that [SA Police] SAPOL, which was a participant in the investigation, would also not have recognised [the father's] background as an essential element in the investigation.
"Equally perplexing is the blind eye that was turned to the criminality of [the father's] behaviour regarding cannabis and that of his supplier or suppliers."
Mr Schapel said Families SA took "no particular notice" of the father's cannabis habit.
He said this case demonstrated how the effect of cannabis use should never be underestimated by social workers.
"There is, I find, a worrying tendency within the child protection environment to regard cannabis consumption as having limited importance and to downplay the dangers associated with the consumption of cannabis within a family setting such as this," Mr Schapel said.
Ebony's case file closed on an 'erroneous' basis
During the inquiry, Mr Schapel also found Ebony's case file had been closed on an "erroneous basis" by Ms Parenta one month before her death.
All this court can do is to repeat the recommendation made by the State Coroner in the matter of the death of Chloe Valentine ...
Deputy Coroner Anthony Schapel
Mr Schapel said Ebony's file should have been reopened after further concerns were raised about the baby.
"All this court can do is to repeat the recommendation made by the State Coroner [in 2015] in the matter of the death of Chloe Valentine, that a proper assessment should be undertaken to ascertain the most effective resource allocation method for Families SA," he said.
"The assessment should include a consideration of the volumes of work and what resource effort is needed to carry out the work satisfactorily."
He further added that police should have better investigated a report of domestic violence involving the parents before baby Ebony's death.
He said the officers who visited the couple's Brooklyn Park unit knew an "incident" had taken place, but not that it involved domestic violence, because that detail was not included in the police computer system.
"[The mother] failed to report it when spoken to by police, and the independent witness who had seen and reported the matter was not spoken to," Mr Schapel said.
"Thus it was that no offence was detected by police when it should have been."
