There were enough warning signs to require a ward of the state to be supervised when he visited his baby, who he fatally bashed in a regional West Australian hospital, a parliamentary committee has found.
The father, who was 15 when he attacked his four-week-old son while visiting him and the 16-year-old mother at Bunbury Regional Hospital in February 2014, was sentenced to 10 years in detention after pleading guilty to manslaughter.
The baby had been born six weeks prematurely and was two days away from being discharged into the care of his parents.
On Thursday, a parliamentary committee handed down its findings from a review of the Department for Child Protection's management of the troubled teenager, concluding multiple red flags were raised in relation to his behaviour.
But the teenager had not been supervised, possibly due to a lack of staff and resources.
In sentencing the teen, who came from a troubled background and had a history of offending and aggressive behaviour, Children's Court of WA President Judge Denis Reynolds expressed surprise that his access to the baby had not been conditional and/or monitored.
The youth's mother also stated that he was meant to be supervised when visiting the baby.
"This may have been due to a lack of staff and resources rather than a conscious decision to allow him unsupervised access," the parliamentary committee said.
While the baby was assigned a Bunbury-based case worker, the teenager's case was handled by two because he had moved between districts.
That required constant communication and added to their workload, possibly resulting in the teen receiving less attention than the mother and baby.
Committee chair Margaret Quirk said the tragedy was a symptom of a system under immense pressure, with the number of children entering care continuing to grow, more than doubling since 2006.
"The union told the committee that a lot of this is about resourcing and there's simply not enough child protection workers to go around," she told parliament.
"They feel immense pressure and are carrying out very significant workloads."
The committee found there was a direct nexus between staffing levels and the capacity to monitor and supervise.
"Staffing at a sustainable level, along with appropriate practices, would help to prevent a similar death from occurring."
