A ‘child death review’ process is designed to review child protection deaths: that is, child deaths attributed to abuse or neglect or deaths of children formally known to the child protection authority, regardless of the cause of death.

The primary aim of the child death review process is to identify whether any failings of the child protection system may have in some way contributed to a child’s death.

Based on the lessons learned from individual deaths the child death review body is able to recommend ways to improve departmental practice, policy, legislation or interagency relationships to reduce the likelihood of future deaths occurring in similar circumstances and to better serve all children who come into contact with the system.

The principal purpose of the child death review process is therefore to provide a mechanism for reviewing the effectiveness of the child protection system. It is a quality assurance mechanism specific to the child protection system.

Child death committees operate (or are being established) in all other states and territories and most other parts of the world. The child death review process is intended to complement other processes for the specific investigation of deaths such as coronial processes and medical paediatric sub-committees.

The current report

The current report covered the deaths of 10 children recorded on the register of paediatric deaths as having had an involvement with the child protection system.

This included 7 children who died in 2005 and 3 who died in 2006.

In addition to this report, a report from a full review of another child who died in 2005 was released in November last year.

The child death review committee has also recently completed a review of a child who died of SIDS in 2007.

There is one outstanding death from 2006 that has not been reviewed - a seventeen year old whose death has been investigated by the coroner and does not appear to be related to her involvement with the child protection system. It is unlikely that a child death review would be productive in this case.

The current report

Of the deaths covered by this report:

  • 2 children were found to not be known to the child protection system before they died and they were therefore not reviewed. The child protection system was only notified of these deaths subsequent to the deaths.
  • 3 died of natural causes or as a consequence of a disability that was unrelated to the child protection system
  • 2 died of sudden infant death syndrome
  • 3 were classified as deaths resulting from suspected abuse or neglect

While the review committee concentrated on the three deaths that were recorded as suspected as resulting from abuse of neglect, the committee also investigated the involvement of the other children with the child protection system, even though their deaths were not suspected as being associated with abuse or neglect. This wider investigation was designed to identify any factors that may have been involved in their quality of life and any overall systemic issues related to the child protection system.

In the case of the two deaths not known to the child protection system, one of the children died from a significant congenital disability and the other died of suspected SIDS. There is no suggestion that the child protection system could have intervened to prevent these deaths, if they had been notified.

Release of the report

As is the case in other states and territories, details of the results of investigations remain confidential so that individual cases are not able to be identified. However, the detailed findings have been discussed with the staff involved in the cases and the full report has been provided to the Director of Children and Family Services and the Commissioner for Children. Briefings have also been provided for the Opposition and Greens.

Progress on implementation of recommendations

The progress in implementation of recommendations from the child death review released in November 2005 is also provided on this site.

Action that is already being taken in the areas identified by recommendation of the current report is also provided on this site.