Australia's child safety system is stretched and high-risk cases which require further scrutiny can get lost, a Tasmanian court has heard.
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A coronal inquest into the deaths of six infants and one child continued before Coroner Olivia McTaggart in Hobart on Tuesday.
The seven children, aged between two months and 16 years, died in the North or the North-West between 2014 and 2018.
READ MORE: Actions of child safety services probed
All seven children were known to child safety services.
The 16-year-old and her infant died as the result of a car accident, four infants died from Sudden Infant Death Syndrome as the result of inappropriate sleeping arrangements, and one infant drowned in a bath after being left unattended.
An expert, who prepared a report on the cases for Ms McTaggart, told the court on Tuesday child safety services staff were under constant pressure to close their cases quickly.
Identification of the witnesses and the families in this inquest is prohibited by a suppression order.
The expert said staff made assessments without access to all the relevant information and little to no referrals were made to support services.
"The really high-risk cases can get lost in the demand," the expert said.
"With the system becoming stressed and stretched, mistakes are made."
The expert said lessons could be taken from the health sector, a field where accidents happened.
"When hospitals and health departments bunker down and in a defensive way seek to avoid accountability it just makes it worse," they said.
"The inquiries have to become much more of a learning experience."
The expert said child safety services needed to have a robust evaluation process which involved children and parents.
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In reference to the deaths of the 16-year-old and her infant, the expert said actions by the department, Tasmania Police and hospital staff had put the girl and her child at the centre of their responses but there had been inadequate face-to-face contact between the department and the girl, and between the department and the infant's father.
But the expert acknowledged it was reasonable the department would not have foreseen by not intervening there would have been a car accident.
In relation to the death of another infant involving an Aboriginal family, the expert said colonisation, the dispossession of Aboriginal people, and economic and social disadvantage meant Aboriginal families were less likely to engage with child safety services.
The expert said among Aboriginal communities there was an established and justified belief the department would only remove their children after the events of the Stolen Generation.
"Many Aboriginal people feel the system has abandoned them" the expert said.
"Aboriginal people have been saying this for many moons."
The expert said Scandinavian countries took a different approach to child safety than Australia.
"I wouldn't call any of the Australian justifications ideal," they said.
"The level of support that is provided in Scandinavian counties is far beyond what is offered [in Australia]
"A family that is scared and stressed may be offered childcare ... they may be offered financial assistance if that's a driving factor.
"The most effective protection of children occurs when there is shared responsibility, and that's not just formal supports but also informal."
But the expert noted one common criticism of Scandinavia's child safety approach was a reluctance to intervene in cases requiring young children.
The inquest continues.