A CORONER has labelled Family and Community Services a "system that is broken" at the inquest into the death of baby following a home birth near Lismore last year.
Deputy State Coroner Harriet Grahame made the statement when she was hearing evidence from Lismore Family and Community Services manager Lisa Gava yesterday.
Ms Gava told the court FACS was notified of a risk of serious harm on February 4, 2015, after a report was made to the Child Wellbeing Unit about the impending birth.
She said the case manager involved triaged the CWB as a non-risk of serious harm as there were no factors such as substance abuse or domestic violence involved.
The court heard that 75% of matters referred to FACS in February 2015 as a risk of harm had not been allocated to case managers.
"It sounds like a system that is broken," Ms Grahame said.
"At that particular time it was apparent that we had significant demands....about children that we had concerns about right then and there," Ms Gava said.
"If we had the resources to allocate a case worker, that would have been the course, to visit the parents at home."
FACS had three reports in February 2015 about planned home births in the Lismore area, Ms Gava said.
Ms Gava wasn't able to review the case managers decision until February 13, just three days before the birth.
Since the baby's death, Ms Gava said FACS had made several changes to its processes.
She said reviews of case closer decisions happened much quicker, a pre-natal reports are discussed at a management meeting, all matters that are reported to the CWU attract a high risk birth alert and the service discovered it couldn't rely on the CWU to contact NSW Health.
Earlier yesterday, Dr Daniel Oxley, who was on call at Nimbin Hospital on the evening of the home birth, said he didn't think he could change the parents mind about a home birth.
When asked by Ms Grahame what sort of complications could have arisen during the birth, Dr Oxley replied "There's the potential for catastrophic events, as happened."
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