An inquest into the death of a toddler, who died after falling into a septic tank in Central Australia, has heard about a string of departmental failures to address safety issues in the remote community.
Aboriginal and Torres Strait Islander readers are advised that this article contains the last name of an Indigenous person who has died, used in accordance with the wishes of his family.
Two-year-old Kumanjayi Fly fell into a septic tank in his grandmother's backyard in Mt Liebig, a remote community about 300 kilometres west of Alice Springs, on March 29 last year.
He was flown to Adelaide's Women's and Children's Hospital but later died on April 3.
On Friday, the toddler's family filled the back of a room in the Alice Springs Local Court where the inquest, presided by Northern Territory Coroner Elisabeth Armitage, was held all week.
In an opening statement, counsel assisting the coroner Fiona Kepert said the toddler loved listening to music, especially gospel songs.
"When Your Honour attended Mt Liebig last week, the family played one of Kumanjayi's favourite songs," Ms Kepert said.
"I think we could all picture this happy toddler dancing and listening to the song."
Septic tank was 'non-compliant'
The inquest heard that a 2019 plumbing report found the septic tank the toddler fell into was one of several in the remote community in "poor condition."
On Friday, Ms Kepert questioned staff at the territory's former Department for Infrastructure Logistics and Planning about why the report and several other safety risk warnings were ignored.
The inquest heard various safety risks had been identified with the septic tank that Kumanjayi Fly fell into. (Supplied: NT Courts)
Ms Kepert asked former Room to Breathe remote housing project manager Stuart Munnich why he had failed to act on the report, which found the septic tank was "non-compliant".
"I don't know what it means when it says it's non-compliant," Mr Munnich said.
"We're all under extreme pressure to meet deadlines and targets."
Mr Munnich agreed he had read the report in 2019, but "not in detail".
He said in hindsight he should have referred it to senior management.
"I would have escalated that, or at least got somebody with technical expertise to actually go out and have a look at the site," he said.
Coroner Elisabeth Armitage says the inquest is examining the infrastructure department's failings. (ABC News: Michael Franchi)
The coroner questioned George Timson, the program director of Room to Breathe, to whom Mr Munnich reported, about why he had not seen the report until the inquest was called.
"How is it that that report could be commissioned, paid for, obtained and not come to your attention?" Judge Armitage asked.
Mr Timson, who is now an infrastructure department housing program senior director, backed Mr Munnich's statement that "high demand" was putting pressure on employees.
He said government programs needed to be "adequately resourced" to avoid such mistakes.
"Processes weren't that good at the time," Mr Timson said.
"Clearly [there were] repairs and maintenance that needed to happen there.
"Had I known also about the previous repairs, I would have escalated to a much higher level."
Fiona Kepert says the tenants at the Mt Liebig site had reported multiple maintenance issues over the years. (Supplied: NT Courts)
Judge Armitage noted that Mr Timson had "access to a whole lot of other information".
"You had evidence and you didn't enquire or look," she said.
"I'm pretty sure if anyone had spoken to any of the families on the ground, they would have told you.
"There were … consultation meetings that discussed things like working and maintenance of those homes."
Maintenance issues 'buried'
In an emotional exchange, Ms Kepert questioned housing program general manager Dwayne McInnes about how a range of safety risks were missed.
"This wasn't overlooked, it wasn't swept under the carpet, it was buried, and a two-year-old boy died," Ms Kepert said.
Mr McInnes said he had not been made aware of the maintenance issues and that he would have prioritised repairs despite budget constraints.
"If I'd known about the conditions of the tanks, I would have told them that [maintenance] needs to be done," he said.
"Nothing I did was in any way trying to shortcut programs that cost a poor child his life."
Judge Armitage says her recent visit to Mt Liebig had revealed ongoing safety issues. (Supplied: NT Courts)
Department culture under scrutiny
The coroner said the inquest was looking into why the safety risk warnings were "ignored" and the department's failings as a whole.
"Given how many people knew about these issues, what was it in the culture that allowed it to go, first of all, unrecognised and then unresponded to," she said.
The coroner said she had visited Mt Liebig the previous week and that safety issues were still "evident" and being "walked past".
Mr McInnes said a preventative government program to maintain septic tanks was underway and that a septic replacement program would begin later this year.
Department of Logistics and Infrastructure portfolio management director Peter Lilliebridge said an audit of homes in several remote communities, including Mt Liebig, Kintore and Papunya, would be complete by the start of the next financial year.
All infrastructure department witnesses apologised to the family members present in court.
Brendan Boyce, representing the Department of Housing, also apologised to the family and committed to the department "doing everything" possible to prevent such an incident from occurring again.
The inquest was unable to finish hearing from all the witnesses last week and was adjourned to a later date.