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Annual report of inquiriesinto the deaths of childrenknown to Child Protection 2012Victorian Child Death Review Committee

Annual report of inquiries into the deaths of children known to Child Protection 2012 Victorian Child Death Review Com

mittee

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Published by Offi ce of the Child Safety Commissioner, Melbourne, Victoria, Australia.June 2012© Copyright State of Victoria, Offi ce of the Child Safety Commissioner, 2012.Th is publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.Authorised by the Victorian Government, 570 Bourke Street, Melbourne.ISSN 2200-4912Th is document can be viewed at: www.ocsc.vic.gov.au/vcdrc

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Annual report of inquiries into the deaths of children known to Child Protection 2012Victorian Child Death Review Committee

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Victorian Child Death Review Committee v

Foreword

Th is is the seventeenth annual report of the Victorian Child Death Review Committee (VCDRC).Th e committee has now moved into the fi nal phase of its work as an external ministerial advisory committee with the release of the Victorian Government’s Directions Paper May 2012 Victoria’s Vulnerable Children. Our Shared Responsibility.Th is report announces the intention to establish a Commission for Children and Young People in line with a key recommendation of the Protecting Victoria’s Vulnerable Children Inquiry that identifi ed the need to strengthen the oversight of Victoria’s system for protecting vulnerable children. Th e function which has been performed by the VCDRC will become part of this new Commission and processes regarding the review of child deaths known to Child Protection will be streamlined and improved. Th e committee welcomes these changes which are in line with its submission to the Protecting Victoria’s Vulnerable Children Inquiry that outlined the evolution of Victoria’s approach to reviewing child deaths. I have continued my role as Chair during the transition period while the new arrangements are coming into eff ect.Over the period of its operation the VCDRC has played an important role in promoting learning as well as in relation to transparency and accountability. Th e committee was established in 1995 as a multidisciplinary ministerial advisory committee. It functioned as an external review mechanism independent of the government department then responsible for both the delivery of Child Protection services and the conduct of inquiries into the deaths of children known to Child Protection. Th e establishment of the Offi ce of the Child Safety Commissioner in 2005 saw the transfer of responsibility for the conduct of child death inquiries into that Offi ce, separate to the Department of Human Services business unit responsible for program development and service delivery of Child Protection.

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Annual report of inquiries into the deaths of children known to Child Protection 2012vi

Th e VCDRC maintained its separate role but over time, due to the complementary roles of the Offi ce of the Child Safety Commissioner and the VCDRC in relation to child deaths, it increasingly came to be perceived as part of the Offi ce of the Child Safety Commissioner. Th e planned establishment of a Commission for Children and Young People will consolidate the child death review function within a single independent body.In this reporting period the VCDRC has experienced an increased level of activity as it completed an increased number of reviews of child deaths resulting from the Children Legislation Amendment Act 2009 which introduced new policy expanding the eligibility timeframe for child death inquiries dating back to 2007. Th is brought a greater number of deaths within scope of the work of the Offi ce of the Child Safety Commissioner and the VCDRC.In presenting the work of the committee, I wish to emphasise that overall Child Protection practitioners and staff from a range of other health, welfare, educational and specialist services work hard to improve the lives of vulnerable children and their families. Child death inquiries must focus on lessons that can be learnt; this leads inevitably to an emphasis on what could have been done better – this does not mean that good practice has not also been a feature of reviewed cases. When reading this report, it is also important to appreciate that Victoria’s child death review system is not adverse event driven; it examines all cases of child deaths known to Child Protection including deaths from congenital and acquired illness. Th e focus of child death inquiries and the work of the VCDRC are not on whether these deaths were preventable. Th e work is about examining routine practice and service delivery so that lessons can be learnt about routine practice. Strengthening routine practice will both reduce the likelihood of adverse events and strengthen general practice. In this reporting period, the committee’s attenti on has been drawn to key messages to strengthen core elements of practice. Th ese messages are relevant not just for Child Protection but for all those services that contribute to the protection of children.On behalf of the VCDRC, I hope that the information in this report will be useful to all those involved with protecting children and promoting their welfare.

Carol Reeves ChairpersonVictorian Child Death Review CommitteeJune 2012

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Victorian Child Death Review Committee vii

Th e Victorian Child Death Review Committee (VCDRC) wishes to thank everyone who has assisted with the preparation of this report.

Bernie Geary, Victorian Child Safety Commissioner, is a strong advocate of the committee’s role and his leadership and commitment to continuous improvement in Child Protection, family and related services is appreciated.

Th e committee considers reports prepared by staff of, or appointed by, the Offi ce of the Child Safety Commissioner. Th e ability of the committee to fulfi l its role is dependent upon the quality of these reports and, on behalf of the committee, I acknowledge the valuable contribution of the inquiry team.

Th e committee also expresses its appreciation to the many practitioners across numerous services working with vulnerable children and their families together with all the Child Protection staff who participated in child death inquiries. Th is involvement is crucial in enabling the child death inquiry process to understand the important work they do and to discern key issues for practice improvement and service development.

Th e Department of Human Services is the key stakeholder in the child death inquiry and review process as the function of the committee is intended to contribute to continuous improvement of Victoria’s Child Protection services. Th e department’s contribution to the process, including the provision of timely and considered responses to fi ndings and recommendations, is greatly appreciated.

Finally, the VCDRC is supported by Executive Offi cer, Ms Karen Elford, who has overseen the production of this report. Her commitment and expertise enable the committee to discharge its obligations eff ectively and her contribution is highly valued by VCDRC members.

Acknowledgements

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Victorian Child Death Review Committee ix

Contents

1 Introduction 1

2 Th e Victorian Child Death Review Committee and Victoria’s child death inquiry process 3

3 Child deaths occurring in 2011 13

4 Analysis of child deaths from 1996–2011 17

5 Child death inquiries reviewed in 2011–12 31

6 Th e year in review; the year ahead 59

References 62

Legislation 63

Glossary and abbreviations 64

Appendix 1 VCDRC recommendations 2011–12 66

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Annual report of inquiries into the deaths of children known to Child Protection 2012x

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Victorian Child Death Review Committee 1

1. Introduction

Th is report has been prepared by the Victorian Child Death Review Committee (VCDRC), an external, multidisciplinary ministerial advisory body. It is tabled in parliament as part of a continuing commitment to a transparent and accountable response to deaths within the Child Protection population.

Th e annual report serves two related, but distinct, functions. First, it provides quantitative and demographic data about the deaths of all children referred to the Child Safety Commissioner by the Department of Human Services, in accordance with the provisions of the Child Wellbeing and Safety Act 2005. Th ese deaths are also placed within the context of an analysis of trends in child deaths from 1996. Second, it provides qualitative analysis of child death inquiries reviewed by the VCDRC between April 2011 and March 2012. Th e aim of this analysis is to identify common themes, issues and opportunities for learning that can infl uence future policy, procedures and practice within Child Protection and related service systems.

Th e 2012 annual report is structured as follows:

• Section 2 provides an outline of the composition, role and function of the VCDRC within the broader context of Victoria’s child death inquiry processes.

• Section 3 provides quantitative and demographic data about the deaths of children known to Child Protection that occurred in 2011.

• Section 4 provides an analysis of trends in child deaths from 1996, when the fi rst VCDRC annual report was tabled in parliament.

• Section 5 provides a qualitative analysis of child death inquiries reviewed by the VCDRC in this reporting period. It also includes a description of child and family characteristics and an analysis of related practice and policy themes.

• Section 6 discusses other work of the VCDRC in the reporting period and describes the committee’s focus and priorities in the coming year.

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Annual report of inquiries into the deaths of children known to Child Protection 20122



2.1 Victorian Child Death Review CommitteeTh e Victorian Child Death Review Committee (VCDRC) is a multidisciplinary ministerial advisory body that reviews the deaths of children and young people who were clients of the Victorian Child Protection service at the time of their death or within 12 months of death.

Th e committee has operated since 1995 as an oversight mechanism of Victoria’s child protection system in relation to the examination and public reporting of deaths of children known to Child Protection.

Victoria has a two-tier system of examining deaths of children known to Child Protection. In the fi rst instance, the Child Safety Commissioner has the statutory responsibility to conduct child death inquiries for each death which falls within the legally defi ned scope of having been known to Child Protection at the time of death or within 12 months of death. Each child death inquiry is subsequently considered by the VCDRC. As a second tier review mechanism, the VCDRC does not itself initiate or undertake any investigative role in compiling information relating to child deaths. Th e committee depends on the timeliness and quality of child death inquiry reports to undertake its work.

Th e VCDRC considers each child death inquiry report, identifi es any issues relating to each case and, importantly, seeks to identify learnings across cases. Th e committee provides expert advice to the Minister for Community Services on policy, procedure and practice issues arising from each matter considered as well as themes that consistently emerge across cases. Th e VCDRC also prepares an annual report that is tabled in parliament as part of a continuing commitment to a transparent and accountable response to deaths within the Child Protection population.

2. Th e Victorian Child Death Review Committee and Victoria’s child death inquiry process



2.2 A window into routine practice

Child death inquiries are not initiated due to practice failures. Th e trigger for a child death inquiry is not linked to perceived poor performance of Child Protection but rather the fact of its involvement, no matter how minimal, in the child’s life. Th e level of involvement can range from minimal to signifi cant.

Child death review mechanisms have increasingly become a component of the quality improvement and accountability processes relating to Child Protection programs and associated services working with vulnerable and endangered children.

While child death review processes now exist within most national and international jurisdictions, the approaches vary considerably, refl ecting the diff ering welfare, legal and cultural contexts within which they exist.

In Victoria, child death reviews are undertaken in relation to all deaths that fall within the legally defi ned scope. Th is approach means that all cases, regardless of the cause of death, are fully examined ‘to promote continuous improvement and innovation in policies and practices relating to child protection and safety’ (s.33(2)) Child Wellbeing and Safety Act 2005.

Th e purpose of child death reviews is to promote learning. Learning is central to service system improvement. While the ability to identify learnings is not restricted to circumstances in which children have died, these cases are an important cohort to examine in relation to potential learnings. Th e process of child death inquiries is essentially an audit of case practice and service provision triggered by each child death.

As the Victorian approach is not adverse incident driven, the reviews do not focus attention on the circumstances of the death but more holistically on whether case practice and case management were adequate and appropriate in providing a service to the client. By looking at all child deaths rather than just those deaths resulting from abuse and/or neglect which potentially cast doubt on the performance of the system, it is possible to build knowledge and understanding of how services operate in general and, in turn, to identify patterns associated with either enhancing or hindering eff ective service delivery to clients.

In this way the child death review system provides a window into routine practice and contributes to fostering a learning and development culture.



2.3 VCDRC membershipTh e VCDRC’s membership is drawn from the health, welfare, police, legal and academic fi elds, mirroring the many professional groups involved in Victoria’s Child Protection system. As such, the VCDRC is well placed to consider the relationships between diff erent systems that impact on vulnerable children and families and to model collaborative practice that is known to be essential with high risk families.

Current membersMs Carol Reeves (Chairperson)Human Services Consultant

Ms Brenda BolandRegional Director, Southern Metropolitan Region, Victorian Department of Human Services

Dr Neil CoventryDirector, Child and Adolescent Mental Health Service, Austin Health; Deputy Chief Psychiatrist – Child and Youth, Victorian Department of Health

Mr John LeatherlandHuman Services Consultant

Ms Yvonne LukeAboriginal Services Consultant

Ms Robyn MillerPrincipal Child Protection Practitioner, Victorian Department of Human Services

Detective Senior Sergeant Tom NairnSexual Off ences and Child Abuse Investigation Team (SOCIT) Project, Victoria Police

Dr Rosemary SheehanAssociate Professor, Department of Social Work, Monash University

Dr Anne SmithMedical Director, Victorian Forensic Paediatric Medical Service

Ms Paresa SpanosCoroner, Coroners Court of Victoria

Mr Bill StronachAlcohol and Drug Services Consultant



Ms Sandie de Wolf AMChief Executive Offi cer, Berry Street Victoria

Retired membersSenior Sergeant Dagmar AndersenStation Commander, Victoria Police

Membership changesIn the past year Senior Sergeant Dagmar Andersen completed her term of appointment on the VCDRC. Th e committee would like to acknowledge the signifi cant work carried out by Senior Sergeant Andersen and express its appreciation for her dedication and professionalism.

Th e VCDRC was pleased to enlist the support of three new members: Ms Yvonne Luke, Detective Senior Sergeant Tom Nairn and Dr Anne Smith. Th ese new members bring signifi cant knowledge and skill from professional experience and longstanding interest in child welfare matters.

2.4 Terms of reference of the VCDRCTh e terms of reference of the VCDRC are:

1. To review the deaths of all children and young people who were clients of the Victorian Child Protection service at the time of their death or within 12 months of their death and advise the Minister for Community Services of the committee’s deliberations.

2. To identify particular groups of child deaths that may benefi t from further investigation or research.

3. To analyse and comment on any themes, trends or patterns that emerge from the review of inquiry reports.

4. To comment on service and system responses to children and families arising from the review of inquiry reports and receive feedback on the implementation of service system reforms.

5. To provide advice to the Minister for Community Services on the child death inquiry process.

6. To prepare an annual report for the Minister for Community Services.

7. To perform other functions in relation to child deaths as directed by the Minister for Community Services.



2.5 Th e Offi ce of the Child Safety Commissioner – child death inquiry process Establishing a child death inquiryTh e Child Wellbeing and Safety Act 2005 contains provisions regarding the conduct of child death inquiries. Th e Act states that the object of such inquiries is to promote continuous improvement and innovation in policies and practices relating to child protection and safety (s.33(2)).

All children who are clients of Child Protection at the time of their death or within 12 months of their death are recorded on the Child Death Register held in the Offi ce of the Child Safety Commissioner’s Inquiries and Review Unit.

Th e Department of Human Services provides the Offi ce of the Child Safety Commissioner with comprehensive documentation about the death of each child. Th e documentation includes critical incident reports and ministerial briefi ngs. Th e receipt of these documents marks the beginning of the child death inquiry process.

An Inquiries and Review Unit practice reviewer is responsible for managing the inquiry process and ensuring the production of a high quality report. Th e practice reviewer may conduct the inquiry, or, if specialist advice regarding specifi c case issues is required will engage and work collaboratively with an external case analyst.

Conducting a child death inquiry Individual child death inquiries are designed to establish the facts of the Child Protection case; ascertain whether established Child Protection procedures, standards, guidelines and protocols were followed in the management of a case; and examine whether the case management decisions and actions of the Department of Human Services and other agencies were adequate and appropriate in providing a service to the client.

Th e child death inquiry process uses a refl ective practice approach in which all participants have an opportunity to think about ‘why’ and ‘how’ decisions were taken and the context in which practice took place. Th e entire case history is revisited. Th e inquiries do not set out to investigate the factors leading to a child’s death or to determine culpability; this is properly the role of Victoria Police and the coroner. Th e aim of the process is to distil key learnings that will infl uence future policy and practice approaches, both regionally and at a program level.



Individual child death inquiries are conducted and reported in a standardised format. Risk assessment, case planning, record management, service collaboration and regional contextual issues are examined in each case. Th is ensures every death is subject to consistent and rigorous review.

Th e confi dentiality of client, family members and other persons and services involved with the case is maintained, consistent with relevant government legislation.

Th e child death inquiry process relies on the participation of relevant workers within the Department of Human Services, community agencies and experts in relevant fi elds. Th e Child Wellbeing and Safety Act 2005 requires a range of health and human services to provide information to the Child Safety Commissioner about a child who is the subject of an inquiry. Families and carers of the deceased child are also invited to contribute.

Revisiting the death of a child or young person is an emotional experience for all those involved. Th e Inquiries and Review Unit briefs participants on the inquiry process and provides support services when required.

Child death inquiry reportsTh e child death inquiry reports produce fi ndings arising from the investigation process.

Each draft child death inquiry report is forwarded to the Department of Human Services and relevant extracts are forwarded to other key stakeholders for comment. Th e report takes into account regional action taken in response to the death and statewide program development relevant to the issues in the case.

Th e fi nal inquiry report is forwarded to the VCDRC along with key Department of Human Services’ documents and coronial documentation, where this is available. Th e VCDRC reviews each child death inquiry report and advises the Minister for Community Services of its deliberations in each case as well as trends and patterns that are identifi ed across cases.

Group analysis of child deathsTh e Child Safety Commissioner can initiate an analysis of a group of child deaths that share similar characteristics, such as where child neglect has been the primary issue. Th e VCDRC may request the Child Safety Commissioner to initiate a group analysis based upon its consideration of child death inquiry reports over time.

Issues and patterns that have been identifi ed may benefi t from further exploration of improved ways of intervening before detailed recommendations can be made about changes to policy and practice.



Th e group analysis process allows for more comprehensive examination of the issues arising from a particular group of deaths, within the context of current research and practice knowledge. It provides for the identifi cation of best practice principles, as well as current gaps or defi cits in service provision.

Figure 2.1Child death inquiry model for the 2011–12 reporting period

Child death

Department of Human Services (Critical incident reporting

process commences)

Offi ce of the Child Safety CommissionerInquiries and Review Unit

(Child death inquiry process commences)

Victorian Child Death Review Committee(Second tier review commences)

Minister for Community Services

Secretary,Department of Human Services;

Children, Youth and Families Division

Offi ce of the Child SafetyCommissioner

Child death group analysis

Victorian Child Death Review Committee

Offi ce of the Child Safety CommissionerInquiries and Review Unit

optional



2.6 Other authorities involved with child deaths in VictoriaA number of offi cial bodies are involved when a child dies in Victoria. Each plays a distinct and specialised role.

Registrar of Births, Deaths and MarriagesWhen a child dies a medical practitioner is required, where able, to certify the cause of death. A funeral director is then engaged to make necessary arrangements. Both the medical practitioner and the funeral director are required to inform the Registrar of Births, Deaths and Marriages of the death. Th e information they provide on standard forms enables the Registrar to offi cially register the death.

Th e State Coroner and Coronial ServicesIf the medical practitioner who examines the child is unable to determine the cause of death or the death is otherwise a ‘reportable’ death under the Coroners Act 2008, the death must be referred to the State Coroner. Reportable deaths include those that are unexpected, unnatural or violent, or have resulted directly or indirectly from accident or injury. However, where a child dies while in the control, care or custody of the Secretary to the Department of Human Services, the death is reportable irrespective of the apparent cause.

Th e coroner has the ability to make recommendations to any minister, public statutory authority or entity on any matter connected with a death which has been investigated.

When investigating a death the coroner is required to ascertain, if possible, the identity of the deceased person, how the death occurred, the cause of death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1996 – eff ectively the date and place where the death occurred. Coronial investigations are generally undertaken by Victoria Police at the request of the coroner. Emergency response procedures exist in relation to sudden infant deaths.

Reviewable deaths – identifying multiple sibling deathsIn 2003, a new category of ‘reviewable deaths’ was created in law in Victoria to deal with the situation of multiple child deaths in the one family. ‘Reviewable deaths’ include those where there is a second or subsequent child death within the one family. Medical practitioners and funeral directors are required to provide information to the Registrar of Birth, Deaths and Marriages about siblings, alive or deceased, of an infant who has died suddenly and unexpectedly. Th e Registrar of Births, Deaths and Marriages notifi es the coroner of any living or deceased child siblings of a child who has



died. Th e coroner is mandated to investigate these ‘reviewable deaths’ and any subsequent deaths. Th e police are encouraged to seek information about siblings in their investigations of child deaths.

Under the Coroners Act 2008, the State Coroner has the authority to refer the second or subsequent death of a child within the one family to the Victorian Institute of Forensic Medicine for investigation.

A special coordinator has been appointed at the Victorian Institute of Forensic Medicine to oversee the system, support the families during the investigation process and refer them to appropriate services. Th is coordinator will assess, in consultation with other professionals involved, whether a report should be made to Child Protection regarding the protection of sibling(s).

Victorian Institute of Forensic MedicineTh e Victorian Institute of Forensic Medicine is a body corporate established by the Victorian Institute of Forensic Medicine Act 1985. Th e principal functions of the Victorian Institute of Forensic Medicine are to provide services in forensic pathology and related aspects of forensic science, clinical forensic medicine, teaching and research. Pathologists at the Victorian Institute of Forensic Medicine perform post-mortem examinations on deceased persons reported to the State Coroner. Th e Victorian Institute of Forensic Medicine provides specialist medical and scientifi c services to the coroner, police and government agencies. Specially trained paediatric forensic pathologists are available to perform autopsies on children.

Department of Human ServicesWhenever a child death is under investigation by the coroner, the Department of Human Services is notifi ed to determine whether the child was known to the Child Protection service. Similarly, when the Child Protection service is notifi ed of the death of a client, contact is made with the coroner to ensure all parties are aware of Child Protection’s involvement with the child. When a current or recent client of Child Protection dies, the Department of Human Services notifi es the Offi ce of the Child Safety Commissioner. Th is death is then entered onto the Offi ce of the Child Safety Commissioner’s Child Death Register and an inquiry into the case is established in accordance with the terms of reference, which focus on case practice and service provision.

Consultative Council on Obstetric and Paediatric Mortality and MorbidityTh e Consultative Council on Obstetric and Paediatric Mortality and Morbidity is a statutory body established in 1962 under the Health Act 1958 and continued under the Public Health and Wellbeing Act 2008 and is the advisory body to the Minister for Health on mortality, perinatal and



paediatric deaths. Th e council has a public health surveillance, reporting and research role in relation to all child deaths that occur in Victoria. When a child dies, the medical practitioner who certifi es the death prepares a report to the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, which includes a range of demographic and descriptive data. Th ese reports inform the council’s comprehensive annual report on perinatal, infant and child deaths in Victoria.



3. Child deaths occurring in 2011

In 2011 the Department of Human Services notifi ed the Offi ce of the Child Safety Commissioner of 28 child deaths occurring in the calendar year January–December which were in scope for a child death inquiry.

Table 3.1 lists the 28 child deaths from youngest to oldest (not in order of occurrence of death), the categorisation of each death and the locality in which the death occurred.

Of the 28 child deaths listed, three have had an inquiry completed by the Offi ce of the Child Safety Commissioner and have been reviewed by the VCDRC, and are therefore included in chapter 5 relating to cases reviewed in the 2011–12 reporting period. Th e remaining 25 child deaths are anticipated to be reviewed by the committee during the 2012–13 reporting period as child death inquiries are completed.



Table 3.1Deaths of children known to Child Protection in 2011 (N= 28)

Case no.

Age at death Category of death Locality

1 1 day Acquired/congenital illness Metropolitan

2 3 days Acquired/congenital illness Metropolitan

3 3 weeks Pending determination * Rural

4 1 month Acquired/congenital illness Rural

5 3 months Acquired/congenital illness Metropolitan

6 3 months Pending determination * Metropolitan

7 3 months Pending determination Rural

8 4 months Pending determination Rural

9 5 months Acquired/congenital illness Rural

10 5 months Pending determination * Metropolitan

11 6 months Pending determination * Rural

12 7 months Acquired/congenital illness Rural

13 8 months Pending determination Metropolitan

14 9 months Pending determination Metropolitan

15 11 months Acquired/congenital illness Metropolitan

16 1 year Acquired/congenital illness Metropolitan

17 1 year Acquired/congenital illness Metropolitan

18 2 years Acquired/congenital illness Metropolitan


20 3 years Accident Rural




24 16 years Suicide Metropolitan

25 16 years Suicide Metropolitan

26 16 years Drug related Rural

27 16 years Drug related Metropolitan

28 16 years Accident Metropolitan

* pending determination by coroner but information suggestive of SIDS



Category of death 2011Table 3.2Deaths of children known to Child Protection in 2011: category of death by age (N=28)

Category 0–< 6 months

6 months–3 years

4–12years

13–17 years

Total %

Acquired/congenital illness

5 6 1 - 12 43

Accident - 1 1 2 4 14Drug/substance related - - - 2 2 7Suicide - - - 2 2 7SIDS - - - - - -Non-accidental trauma - - - - - -Unascertained by coroner - - - - - -Pending determination 5 3 - - 8 29Total 10 10 2 6 28 100

Table 3.2 provides information on the category of death for children who were known to Child Protection in 2011. Th e Offi ce of the Child Safety Commissioner categorises the cause of death on the basis of information from coronial fi ndings, autopsy reports, forensic reports, medical reports and Child Protection client fi les. For all deaths reported to the coroner the cause of death as determined by the coronial process is relied upon when categorising each death.

Four deaths (14%) in 2011 were due to accidents. All of the four deaths attributed to accidents involved road fatalities. Twelve deaths (43%) were attributed to an acquired/congenital illness. Th e acquired/congenital illness category includes deaths due to congenital conditions, prematurity, malignancy, acute infections and serious health episodes, such as epilepsy or cardiac arrest. Two deaths (7%) were drug related and two deaths (7%) were due to suicide.

For some deaths reported to the coroner, fi ndings are pending determination upon the conclusion of coronial investigations. For this reason, fi gures may alter across annual reports. Of the 28 deaths of children known to Child Protection in 2011, eight (29%) are currently categorised as pending determination; however, this number will decrease once formal determination of the cause of death is known. Th e cause of some deaths at the conclusion of the coronial process will be determined to be unascertained.



Age and gender of children who died in 2011Table 3.3Deaths of children known to Child Protection in 2011: age and gender (N= 28)

0–< 6 months

6 months–3 years

4–12 years

13–17 years

Total %

Male 8 6 1 3 18 64Female 2 4 1 3 10 36Total 10 10 2 6 28 100

Table 3.3 shows that of the 28 children who died in 2011, 36% were infants aged less than six months, 36% were aged between six months and three years, 7% were between four and 12 years and 21% were adolescents aged 13–17 years.

Males made up the majority of deaths in both the 0–


Th is section places the child deaths that occurred in 2011 in the context of analysis of trends in child deaths from 1996, when the fi rst VCDRC annual report was tabled in parliament.

Signifi cant variations occur in the number of deaths of children and young people known to Child Protection each year1. A cautious approach to interpretation of the numbers is warranted because the numbers vary considerably from year to year. Th is volatility refl ects the small numbers of deaths known to Child Protection. In addition, fi gures from 2007 onwards are not directly comparable with earlier annual fi gures because of the expanded defi nition of ‘known to Child Protection’ which applies from this time. Given this expanded defi nition, it is likely that annual fi gures will be higher from 2007.

Consequently, the signifi cance of annual fi gures and death rates are both impacted by small volatile year-to-year numbers and the shift over time in the defi nition of children known to Child Protection. Th e child death review process looks beyond numbers and endeavours to build a comprehensive picture of the individual, family, community and service system issues that are relevant in each child’s case.

1A child known to Child Protection is defi ned in accordance with section 33(1) Child Wellbeing and Safety Act 2005

4. Analysis of child deaths from 1996–2011



Table 4.1Total reports, investigations, substantiations, active clients and deaths known to Child Protection 1996–20112

Year Reports Investigations Substantiations Active clients Total deaths

Death rate

1996 31,010 13,954 6,798 28,337 19 0.671997 32,642 14,606 7,126 29,878 16 0.531998 34,668 14,524 7,649 31,661 11 0.341999 36,291 13,283 7,560 32,268 17 0.522000 36,501 12,446 7,341 32,432 25 0.772001 38,686 13,220 8,015 34,376 12 0.342002 38,850 13,455 7,862 34,430 32 0.922003 38,189 12,618 7,309 34,077 13 0.382004 38,206 12,404 7,897 34,515 16 0.462005 37,242 11,346 7,510 34,710 11 0.312006 37,991 11,526 7,392 36,475 18 0.492007 40,260 11,306 7,107 36,384 22 0.602008 41,934 11,687 6,988 38,763 28 0.722009 44,717 11,826 6,886 42,638 26 0.602010 52,436 14,434 8,977 47,982 29 0.602011 59,282 16,979 9,905 52,723 28 0.53

Th is number may change as investigations are completed Rate of deaths per 1,000 active clients

Changed policy impact: change to counting rule as applies to clients in scope for a child death inquiry

Table 4.1 provides annual data about the number of reports received by Child Protection – the number of reports that are formally investigated, the number where protective concerns are proven or substantiated, and the number of active clients during each period. Th e table also shows the number of deaths of children known to Child Protection and expresses this fi gure as a death rate per 1,000 active Child Protection clients.

2 Updates may result in minor variations to data shown in previous reports.



Figure 4.1Deaths of children known to Child Protection 1996–2011 (N= 324)

0

5

10

15

20

25

30

35

2010 201120092008*200720062005200420032002200120001999199819971996

Impact of legislative change

19 16 11 17 25 12 32 13 16 11 18 16 22 23 24 26

6

73

5 2

Known to Child Protection at time of death or within 3 months of deathChanged Policy: >3 months–12 months*A death which occurred in 2008 was notified to the Child Safety Commissioner in 2011

Figure 4.1 shows all deaths of children known to Child Protection from 1996 to 2011. Th e child deaths in scope as a result of the change in policy enshrined in the Children Legislation Amendment Act 2009 are highlighted in the years 2007, 2008, 2009, 2010 and 2011. Th is change in policy extended the eligibility timeframe to require child death inquiries to be conducted in respect of children who were Child Protection clients from within three months of death, to children who had been Child Protection clients within 12 months of death.



Category of death 1996–2011Figure 4.2Deaths of children known to Child Protection 1996–2011: category of death (N= 324)

0

5

10

15

20

25

30

35Impact of legislative change

2010 201120092008200720062005200420032002200120001999199819971996

Category of death ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08* ‘09 ‘10 ’11 Total %Acquired/congenital illness

4 5 3 5 11 5 9 5 4 4 10 8 10 10 5 12 110 34

Accident 1 3 4 4 4 4 9 3 3 1 4 5 4 2 8 4 63 19

SIDS 6 2 1 2 - 2 8 1 2 1 3 3 5 3 5 - 44 14

Non-accidental trauma

3 3 - 3 3 - 2 2 3 1 - 1 1 4 2 - 28 9

Drug/substance related

3 2 2 1 4 - 1 1 2 - - - 2 1 3 2 24 7

Suicide/self-harm 1 1 - 1 1 1 - 1 - 2 - 1 5 2 2 2 20 6

Unascertained 1 - 1 1 1 - 1 - 1 2 1 4 - 2 3 - 18 6

Pending determination/not known

- - - - 1 - 2 - 1 - - - 2 2 1 8 17 5

Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 29 28 324 100

* A death which occurred in 2008 was notifi ed to the Child Safety Commissioner in 2011

‘08*



Figure 4.2 shows that between 1996 and 2011, the largest category of death among children known to Child Protection was acquired/congenital illness, accounting for 110 cases (34% of total deaths). Th e acquired/congenital illness category includes deaths due to congenital conditions, prematurity, malignancy, acute infections and serious health episodes, such as epilepsy or cardiac arrest.

Th e second largest category was due to accident, accounting for 63 deaths (19%). Of the 63 deaths attributed to accidents, 27 involved road fatalities, 14 deaths were due to drowning and fi ve deaths involved fi re. Th e remaining 17 deaths were due to a range of other causes.

Between 1996 and 2011, there were 44 deaths (14%) attributable to sudden infant death syndrome (SIDS). SIDS is a diagnosis of exclusion, applied when no other cause of death can be confi rmed.

From 1996 to 2011, 28 deaths (9%) were categorised as non-accidental trauma. Th is categorisation includes deaths due to physical abuse, homicide and any instance where a child or young person is missing, presumed dead. Of the 28 cases of non-accidental trauma:

• twelve had no prior Child Protection history

• sixteen were previously known to Child Protection

• half (14) were reported to Child Protection following the injury which resulted in death. Of these 14, two were previously known to Child Protection

• eight were closed Child Protection cases at the time the injury was sustained

• six cases were open at the time the injury was sustained.

From 1996 to 2011, the deaths of 24 young people (7%) were attributed to substance use. Th is category includes cases where death was related to the use of intravenous drugs, inhalants, methadone toxicity and poly-drug use. During the same period, a further 20 adolescent deaths (6%) were categorised as due to suicide/self-harm/risk-taking behaviour.

Between 1996 and 2011, 17 deaths (5%) were categorised as cause of death not known or pending determination. Th is includes deaths that are awaiting a coronial outcome. In a further 18 cases (6%) the fi nal coronial classifi cation of the cause of death was not able to be determined and was deemed unascertained.



Age of children who died 1996–2011Figure 4.3Deaths of children known to Child Protection 1996–2011: age (N= 324)

0

5

10

15

20

25

30

35

2010 201120092008200720062005200420032002200120001999199819971996


Age ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08* ‘09 ‘10 ‘11 Total %0–< 6 months 6 3 3 3 6 4 13 3 5 5 10 8 8 9 9 10 105 326 months–3 years 7 4 4 7 9 2 10 5 5 1 4 6 6 9 8 10 97 304–12 years 2 2 - 3 3 2 3 2 2 - 4 4 5 2 4 2 40 1313–17 years 4 7 4 4 7 4 6 3 4 5 - 4 10 6 8 6 82 25Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 29 28 324 100

*A death which occurred in 2008 was notifi ed to the Child Safety Commissioner in 2011

Figure 4.3 shows that over time, the greatest number of deaths is of infants aged between birth and six months, 105 (32%); followed by children aged between six months and three years, 97 (30%); and young people aged between 13 and 17 years, 82 (25%). Primary school age children make up the lowest number of deaths, 40 (13%).

Infants aged 0–3 years are the most represented age cluster, comprising 62% of all deaths within the known Child Protection population over time.



Gender of children who died 1996–2011Figure 4.4Deaths of children known to Child Protection 1996–2011: gender (N= 324)

0

5

10

15

20

25

30

35

2010 201120092008200720062005200420032002200120001999199819971996


Gender ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08* ‘09 ‘10 ‘11 Total %Male 10 12 8 12 11 6 15 7 8 9 11 12 17 16 21 18 193 60Female 9 4 3 5 14 6 17 6 8 2 7 10 12 10 8 10 131 40Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 29 28 324 100


Figure 4.4 shows that over time, the proportion of male deaths is 60% compared with female deaths at 40%.Table 4.2Age grouping by gender 1996–2011 (N=324)

Gender 0–


Category of death by age groupings: 1996–2011 Th e VCDRC has found it instructive to analyse category of death by age over time. Th e following discussion analyses category of death in each of three main age groups: infants, primary school-aged children and adolescents. Figure 4.5Deaths of children known to Child Protection 1996–2011: category of death by age (N= 324)

0

20

40

60

80

100

120

Pending determination/

not known

Unascer-tained

AccidentAcquired/congenital

illness

SIDS Suicide/self-harm

Drug/substance

related

Non-accidental

trauma

Acqu

ired/

cong

enita

l ill

ness

Acci

dent

SID

S

Non

- acc

iden

tal

trau

ma

Dru

g/su

bsta

nce

rela

ted

Suic

ide/

self-

har

m

Unas

cert

aine

dPe

ndin

g de

term

inat

ion/

not k

nown

Tota

l

%

0–3 years 80 23 44 22 - - 17 16 202 624–12 years 19 17 - 3 - - - 1 40 1313–17 years 11 23 - 3 24 20 1 - 82 25Total 110 63 44 28 24 20 18 17 324 100



Category of death: infants (0–3 years)Figure 4.6Deaths of children known to Child Protection 1996–2011: infants by category of death (N=202)

0

20

40

60

80

100


not known

UnascertainedNon-accidentaltrauma

AccidentSIDSAcquired/congenital illness

80

(40%)

44

(22%)

23

(11%)

22

(11%)16

(8%)

17

(8%)

From 1996 to 2011, there were 202 deaths in the 0–3 age group, which makes up 62% of the total number of deaths. Of the 202 infant deaths, 105 (52%) were younger than six months.

Of the 202 deaths in the 0–3 age group, the most common category of death is acquired/congenital illness, comprising 80 deaths (40%). Th e second largest category of death among infants is SIDS. Between 1996 and 2011, 44 (22%) infants died from SIDS.

Over the 17 year reporting period, 23 (11%) of the 202 deaths among infants aged 0–3 years were categorised as due to accident. Th e majority of these involved drowning, road accidents or fi re.

Between 1996 and 2011, 22 infants (11%) aged 0–3 years died of non-accidental trauma. Th e most common cause of death for these infants is head injury. Signifi cantly, of the 28 deaths across all age groups categorised as non-accidental trauma, 79% were infants aged 0–3 years.

Between 1996 and 2011, 17 infant deaths (8%) were classifi ed as unascertained by the coroner and 16 (8%) were categorised as pending determination. To ensure accuracy, caution is exercised when categorising infant deaths, especially in relation to SIDS deaths.



Category of death: primary school age children (4–12 years)Figure 4.7Deaths of children known to Child Protection 1996–2011: primary school age children by category of death (N=40)

0

5

10

15

20

25

30


not known

UnascertainedNon-accidentaltrauma

AccidentAcquired/congenital illness

19

(48%)17

(43%)

3(8%) 1

(3%)0

From 1996 to 2011, there were 40 deaths among 4–12 year olds (12% of the total deaths).

Of these 40 deaths, 19 (48%) were due to acquired/congenital illness, which includes deaths as a result of a disability, malignancy or acute infection.

Seventeen deaths (43%) were categorised as due to accident in this age group, with drowning and road accidents the most common causes.

Th ree deaths (8%) in this age group were due to non-accidental trauma and one (3%) was categorised as pending determination by the coroner.



Category of death: adolescents (13–17 years)Figure 4.8Deaths of children known to Child Protection 1996–2011: adolescents by category of death (N=82)

0

5

10

15

20

25

30

Unascertained Pendingdetermination/

not known

Non-accidental

trauma

Acquired/congenital

illness

Suicide/self-harm

AccidentDrug/substance

related

24

(30%)23

(28%) 20

(24%)

11

(13%)3

(4%) 1(1%) 0

From 1996 to 2011, there were 82 deaths among young people aged 13–17 years (25% of the total deaths).

Of the 82 deaths in the adolescent age group, the most common category of death is drug/substance related, comprising 24 deaths (30%). Th is category includes cases where death was related to the use of intravenous drugs, inhalants, methadone toxicity and poly-drug use.

Th e second largest category of death among adolescents known to Child Protection was due to accident, with 23 deaths (28%). Most of these deaths involved vehicles, including cars, trains and motorcycles.

Twenty adolescent deaths (24%) were categorised as due to suicide/self-harm/risk-taking behaviour.

Eleven adolescents (13%) died of an acquired/congenital illness. Nine of these young people had disabilities and/or long-term serious illnesses.

Th ree adolescent deaths (4%) were categorised as due to non-accidental trauma. Th is category includes a case where a young person is missing, presumed dead.

For one death (1%) the cause of death was classifi ed as unascertained by the coroner.



Aboriginal status 2000–2011Figure 4.9Deaths of children known to Child Protection 2000–2011: Aboriginal and non-Aboriginal child deaths (N=261)

0

5

10

15

20

25

30

35

2010 20112009200820072006200520042003200220012000


‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08* ‘09 ‘10 ‘11 Total %Non-Aboriginal child 20 9 28 10 16 10 17 19 24 23 26 26 228 87Aboriginal child 5 3 4 3 - 1 1 3 5 3 3 2 33 13Total 25 12 32 13 16 11 18 22 29 26 29 28 261 100


Because the collection of child death information regarding Aboriginal status was inconsistent prior to 2000, data are reported from 2000 onwards.In 2010, Aboriginal children comprised 1.2% of the total number of children 0–17 years in the Victorian population3. Figure 4.9 shows that between 2000 and 2011, there was a total of 261 child deaths, 33 (13%) of whom were Aboriginal children.In 2011, 8% of active clients in the Child Protection population were identifi ed as Aboriginal; consistent with this 7% (two) of the child deaths known to Child Protection were identifi ed as Aboriginal. Aboriginal children are over-represented both within the Child Protection population and within data regarding the deaths of children known to Child Protection. Given the small numbers, caution in interpretation is necessary although the overall interpretation of over-representation of Aboriginal children is accurate. 3Australian Bureau of Statistics



Stage of Child Protection involvement at the time of death 1996–2011Figure 4.10Deaths of children known to Child Protection 1996–2011: stage of Child Protection involvement at time of death (N=324)

0

5

10

15

20

25

30

35

2010 201120092008200720062005200420032002200120001999199819971996


Stage of protective involvement ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08* ‘09 ‘10 ‘11 Total %Intake 1 4 3 6 5 1 4 3 4 1 4 2 4 4 5 2 53 16

Investigation 5 2 2 1 3 - 9 1 6 1 6 8 6 4 5 8 67 21Protective intervention 4 1 1 - 1 1 4 1 2 3 2 1 5 6 4 4 40 12Protection order 3 6 3 4 7 2 5 3 3 2 - 3 4 5 4 3 57 18Closed 6 3 2 6 9 8 10 5 1 4 6 8 10 7 11 11 107 33Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 29 28 324 100


Figure 4.10 shows that 120 children (37% of the 324 child deaths known to Child Protection in this period) were subject to Child Protection intake or investigation at the time of their death. Forty children (12%) were subject to protective intervention and 57 children (18%) were subject to protection orders. Child Protection had ceased case involvement with 107 children (33%) at the time of their death. Th ese fi gures have been updated based on a review of the data.4

4Updates may result in variations to data shown in previous reports



5. Child death inquiries reviewed in 2011–12

Th is section provides an analysis of child death inquiries reviewed by the VCDRC in 2011–12. Th e VCDRC reporting period commenced in April 2011 and concluded in March 2012.

In 2011–12, the VCDRC reviewed a total of 38 child deaths. Four of these deaths occurred in 2007, eight deaths occurred in 2008, fi ve deaths occurred in 2009, 18 deaths occurred in 2010 and three deaths occurred in 2011. Fourteen of the 38 cases reviewed were eligible for a child death inquiry due to the impact of the Children Legislative Amendment Act 2009 which came into eff ect in August 2009.

Th e Children Legislation Amendment Act 2009 amended the Child Wellbeing and Safety Act 2005 to require child death inquiries to be conducted in respect of a child who was a Child Protection client within 12 months of death. Th e extension of the eligibility timeframe from three to 12 months increases the ability to identify learnings and strengthens accountability and transparency in relation to deaths of children who are the subjects of reports to Child Protection.

Th is section describes key child and family characteristics and discusses practice and policy themes arising from the child death inquiries reviewed in 2011–12.



5.1 Characteristics of the children and their familiesTable 5.1Child death inquiries reviewed in 2011–12 (N= 38)

Case No.

Year of death


Stage of Child Protection involvement

1 2010 2 days Acquired/congenital illness Rural Open/intake2 2010 3 days Acquired/congenital illness Metro Open/intake 3 2010 9 days Unascertained Metro Open/Interim

Accommodation Order4 2010 1 month SIDS Metro Open/investigation5 2008 1 month SIDS Metro Open/intake6 2010 2 months Acquired/congenital illness Rural Open/investigation7 2010 2 months Acquired/congenital illness Rural Open/investigation8 2009 2 months SIDS Rural Closed/intake 9 2010 3 months SIDS Metro Open/investigation10 2008 4 months Acquired/congenital illness Rural Closed/intake 11 2010 5 months SIDS Rural Closed/intake 12 2011 5 months Acquired/congenital illness Rural Closed/investigation 13 2010 9 months SIDS Metro Open/protective

intervention14 2010 10 months Non-accidental trauma Metro Open/intake

Reported to Child Protection after the injury causing death

15 2009 1 year Acquired/congenital illness Rural Open/Custody to Secretary Order

16 2009 1 year Acquired/congenital illness Rural Closed/intake 17 2008 1 year Non-accidental trauma Metro Open/intake

Reported to Child Protection after the injury causing death

18 2011 1 year Acquired/congenital illness Metro Closed/intake 19 2007 3 years Acquired/congenital illness Metro Closed/intake 20 2010 5 years Accident Metro Closed/intake 21 2010 5 years Acquired/congenital illness Rural Open/intake

Reported to Child Protection on day of death

22 2007 7 years Acquired/congenital Illness Rural Closed/intake 23 2008 7 years Acquired/congenital illness Rural Closed/intake24 2010 9 years Accident Rural Open/Custody to

Secretary Order25 2008 9 years Accident Metro Open/intake26 2008 10 years Accident Rural Closed/intake 27 2009 11 years Acquired/congenital illness Metro Closed/investigation



Case No.

Year of death


Stage of Child Protection involvement

28 2007 13 years Accident Rural Closed/protective intervention

29 2008 15 years Acquired/congenital illness Metro Closed/intake 30 2010 16 years Accident Rural Open/Supervision Order31 2007 16 years Accident Metro Closed/intake 32 2011 16 years Suicide Metro Open/Custody to

Secretary Order33 2010 16 years Accident Metro Closed/intake 34 2010 16 years Suicide Rural Closed/intake 35 2010 16 years Accident Metro Open/Custody to

Secretary Order36 2010 17 years Drug related Metro Closed/intake 37 2009 17 years Drug related Metro Open/Supervision Order38 2008 17 years Accident Rural Closed/intake

Table 5.1 shows the 38 child deaths reviewed from youngest to oldest (not in order of occurrence of death), the categorisation of each death, the locality in which the death occurred and the stage of Child Protection involvement at the time of death. Of the 38 deaths reviewed:

• nineteen deaths (50%) involved children aged three years or younger• fourteen deaths (37%) involved infants younger than 12 months of age;

eight of these occurred in the context of unsafe sleeping• eleven deaths (30%) involved children aged 13 years or older• six of these 11 adolescent deaths occurred in the context of histories of

multiple (fi ve or more) reports to Child Protection over extended periods

• seven children (18%) were on Children’s Court orders at the time of their deaths

• nineteen child deaths (50%) were open Child Protection cases• twenty deaths (53%) occurred in Victoria’s metropolitan areas and 18

deaths (47%) in rural Victoria.



Table 5.2Child death inquiries reviewed in 2011–12: age and gender (N= 38)

0–


Th e Offi ce of the Child Safety Commissioner categorises each child death based on information received from the Department of Human Services and the Coroners Court of Victoria.

Table 5.4 shows the categorisation of the 38 child deaths in this review period:

• fi fteen deaths were attributed to acquired/congenital illness. Ten of these children were younger than four years and of these, six were infants under 12 months of age

• ten deaths were due to accident including four deaths by drowning and fi ve deaths resulting from motor vehicle accidents

• six infant deaths were attributed to SIDS

• two adolescent deaths were due to suicide and two adolescent deaths were drug related

• two deaths were attributed to non-accidental trauma; both of these children were reported to Child Protection after the incident that led to their death. In both of these cases there was no prior Child Protection involvement

• in another case the coroner was unable to ascertain the cause of death.



Figure 5.1Child death inquiries reviewed in 2011–12: key child characteristics by age (N= 38)

0

2

4

6

8

10

12

Mentalill health

Challengingand high riskbehaviours

Substanceabuse

Educationalissues

Develop-mentaldelay

Multiple disabilities

Complex medical

needs

Limitedlife

expectancy

Neonatalabstinencesyndrome

Inadequateantenatal

care

Pre-maturity

Key child/young person characteristics

0–


• three births featured inadequate antenatal care

• two infants were born drug dependent

• complex medical needs were key child characteristics identifi ed in six infant cases, three children aged 4–12 years and two adolescent cases. Eight children had a limited life expectancy

• seven children had multiple disabilities with the majority of these aged 4–12 years and two children aged younger than four years

• eleven children had developmental delay or intellectual disability; fi ve of these children were aged 4–12 years and fi ve were adolescents

• seven of the eleven adolescents experienced signifi cant disruption to their education

• high risk behaviours including substance use were key characteristics identifi ed in nine of the eleven adolescent cases

• four adolescents had been diagnosed with mental ill health.

Table 5.5Child death inquiries reviewed in 2011–12: care arrangements at time of death by age of child (N= 38)

Two parent families Single parent families

Both parents

Mother and mother’s partner

Father and father’s partner Mother Father

26% 3% 3% 34% 11%32% 45%

Alternative care IndependentKinship care Out-of-home

care placementDid not leave birth hospital Living independently Homeless

3% 8% 5% 5% 3%16% 8%

Table 5.5 shows living arrangements at the time of the child’s death:

• the majority (29) of the children reviewed in this period were in the care of their immediate family

• seventeen children were in the care of a single parent

• three children were living in out-of-home care. One of these children was in a temporary residential placement, one was in a foster care placement and another was residing in specialist disability respite care



• two adolescents were living independently, and one young person was homeless

• two children spent the duration of their life in hospital due to complex medical issues.

Figure 5.2Child death inquiries reviewed in 2011–12: key parental characteristics by age of child (N=38)

0

5

10

15

20

25

Intellectual disability

Transience/homeless-

ness

Parental Child

Protection history

Lack of formal

supports

Social isolation

Intergen-erational trauma

Young mother atfirst child

Familyviolence

Mentalill health

Substanceuse

Key parental characteristics0–


Figure 5.2 shows key parental characteristics that are known to impact on parenting capacity, reduce parents’ ability to provide adequate care and protection, and which are also seen as factors that increase the risk of harm to a child.

Th e VCDRC examines the child death inquiry reports to identify the prevalence of these factors in the families of the children subject to review. Parents usually have more than one of these characteristics.

Th is year the VCDRC found that family violence, a parental background of intergenerational trauma, substance use, and transience or homelessness were identifi ed as the most prevalent factors in the cases reviewed. Mental ill health, a mother aged 20 or younger at the birth of her fi rst child and social isolation were also highly prevalent. Th e existence and co-existence of these parental characteristics occurred in families across all age groupings.

Of the 38 child death cases reviewed:

• family violence was a factor in 20 cases

• a parental background of intergenerational trauma was evident in 19 cases

• parental use of alcohol and/or drugs was a factor in 18 families

• transience or homelessness aff ected 18 families

• parental mental ill health was a factor in 14 cases

• fourteen mothers were known to have been aged 20 years or younger at the birth of their fi rst child

• thirteen families were socially isolated

• in ten families there was a parental history of involvement with protective services as children or adolescents

• eight families appeared to lack connection or engagement with service supports

• Child Protection was also involved with siblings in the majority of these families.



Figure 5.3Child death inquiries reviewed in 2011–12: co-occurrence of parental characteristics: mental ill health, family violence, substance use and intellectual disability (N=38)

34%Predominantly family violence

and substance use or mental ill health and substance use

18%Mainly family violence,

substance use and mental ill health

5%Family violence, substance use,

mental ill health and intellectual

disability

2 risk factors 3 risk factors 4 risk factors

Again in the 2011–12 reporting period, of signifi cance was the co-existence and interaction of the multiple parental risk factors of mental ill health, family violence, substance use and intellectual disability identifi ed in these families:

• thirteen (34%) of the families presented with two of these four parental risk factors, most commonly family violence and substance use (fi ve), and mental ill health and substance use (four)

• seven (18%) of the families presented with three of these parental risk factors, the most common being family violence, substance use and mental ill health

• two families (5%) presented with all four risk factors: family violence, substance use, mental ill health and intellectual disability.



Table 5.6Child death inquiries reviewed in 2011–12: services identifi ed as involved by age of child (N=38)

Services involved0–


Table 5.6 shows the services identifi ed by child death inquiries to have been involved with the children and their families. Th e table does not refl ect the level or quality of involvement of these services. Instead, the table provides a window into the range of services that were known to have had some level of involvement and underscores the importance of collaboration between services to ensure an integrated multi-service response to vulnerable children and their families given:

• the involvement of multiple services both at any one time and over the period of Child Protection intervention in the cases reviewed

• the broad range of child-focused and adult-focused and universal and specialist services involved in the cases reviewed

• the extent of involvement by various other services in cases known to Child Protection

• the signifi cance of sharing case-related information by services involved to enable comprehensive child and family assessment and planning and to identify gaps in service provision.

5.2 Th emes and issuesAs a second tier review mechanism, the key contribution made by the VCDRC to the process of reviewing child deaths known to Child Protection is to identify common themes across cases that have been reviewed in a reporting period.

Whilst each child death inquiry identifi es factors relevant to that particular case, the review function of the VCDRC ensures that collective learning across cases is identifi ed and made available to inform ongoing service system development relating to the protection of children concerning practice, program and policy domains.

In this reporting period, the Offi ce of the Child Safety Commissioner presented the VCDRC with 38 child death inquiries undertaken by that Offi ce for consideration.

A comprehensive case tracking system records cumulative data on more than 50 dimensions of case practice, enabling all client and case practice characteristics to be cross-referenced in each reporting period. Numerically common client and case practice characteristics, together with dimensions of service provision, are distilled from the data set. Th is serves as an evidence base for the committee to consider factors associated with client outcomes and service provision.



Th e VCDRC conducted qualitative analyses of the case practice and service provision relating to these 38 cases and identifi ed the signifi cant themes and issues relating to each of these cases as well as building a picture of common themes and issues across cases.

Th e VCDRC’s capacity to undertake such qualitative analyses derives from its multidisciplinary perspective and the expertise of its members.

A comprehensive presentation of themes and issues relating to the committee’s review of each child death is provided in correspondence to the Minister for Community Services and the Department of Human Services as each case is reviewed. Th e culmination of the review period enables the committee to refl ect on the full cohort of cases considered and provide this summary of key themes and issues.

Th e themes and issues identifi ed by the VCDRC and presented in this report should not be interpreted as contributing to the deaths of the children; these are refl ections on practice and service delivery which are presented as learnings from the case reviews and cannot be inferred as associated with the circumstances of the deaths.

Th ere are fundamental elements of eff ective practice and service delivery to protect children. For this reporting period, the committee has chosen to present the themes and issues discerned from reviewed cases as ‘messages for practice’ associated with each of these core elements.

Th e following ‘messages for practice’ are presented for practitioners and services to consider and refl ect upon in seeking to improve how work is undertaken to protect children rather than as criticisms of past eff orts:

• Th e distinctive role of statutory Child Protection services

• Protecting vulnerable children: a shared responsibility

• Organisational support for the protection of children

• Aptitudes: messages for practice

• Receiving reports: messages for practice

• Information gathering: messages for practice

• Assessment: messages for practice

• Maintaining a focus on the child/young person: messages for practice



• Decision making: messages for practice

• Communication: messages for practice

• Collaboration: messages for practice

• Service provision: messages for practice

• Use of legal authority: messages for practice

• Case closure: messages for practice

Th e distinctive role of statutory Child Protection servicesChild Protection is not easy but it is of vital importance to the community.

Th e protection of children is described as a ‘community responsibility’. Th is term is used to encapsulate that we all – ranging from individual community members to the broad range of organisations that come into contact with children and families to those professional and services charged with particular roles and responsibilities for vulnerable families/parents and endangered children – have a duty towards children.

However, particular services are at the forefront of discharging the community’s aspiration for children to be safe and well cared for.

Th e role of statutory Child Protection embodies the community’s expectation that children not be abused or neglected. Th e distinctive feature of statutory Child Protection services is its role in representing community standards regarding adequate care of children. Statutory Child Protection is the key service which identifi es and interprets on behalf of the community when ‘good enough’ care is not being provided to children and which must act to protect them from abuse and neglect. Th e community, through the legislation that underpins statutory Child Protection, authorises that service to receive and investigate reports of possible abuse and neglect of children and to exercise coercive powers to bring instances where community standards of ‘good enough’ care are in question before the courts – the specialised jurisdiction of the Children’s Court – for fi nal determination.

Th e complexity of the role of statutory Child Protection services stems from encompassing both ‘care and control’ – combining traditional welfare notions of seeking to understand and help alongside the responsibility to exercise legal authority and coercion to intrude on family autonomy to protect children on behalf of the community.

Th is is a heavy responsibility which requires a particular set of aptitudes, knowledge and skills.



Protecting vulnerable children: a shared responsibilityWhilst statutory Child Protection has a distinctive responsibility for the protection of children, this cannot be achieved without working with a broad range of other services at every stage of intervention.

In addition, many children’s situations will fall below the threshold necessitating the intervention of statutory Child Protection services. Th ese situations will range across families requiring minimal supports which assist them to care for their children to more concerning situations which fall only marginally below the threshold warranting statutory Child Protection intervention. Th is continuum of support needs will be responded to through the involvement of a range of welfare, health, educational and specialist services. Collaborative work between these services is imperative and is aimed at assisting parents with a range of issues and thereby improving the quality of care children receive within their families.

Th is also requires aptitude, knowledge and skills towards protecting children.

Th us, whilst children’s safety and wellbeing is a matter for us all, a heavy responsibility is rightly placed both on statutory Child Protection and a broad range of other services to ensure that it happens.

Organisational support for protecting childrenStaff in each of the services which contribute to protecting children have demanding roles. Th ese roles exist within organisational settings which can either enhance or inhibit the ability of staff to enact their responsibilities.

Compromised operating environments – due to workload, staffi ng vacancies and the experience profi le of the workforce – will militate against thorough in-depth practice and reduce the quantity and quality of work that can be done. ‘…ultimately the safety of children depends on staff having the time, knowledge and skill to understand (each) child or young person and their family circumstances’ (Laming, 2009). Good practice and collaborative eff orts across staff will dwindle when operating environments are compromised by resourcing issues. Th e interaction between overwhelmed professionals and overwhelmed families is not conducive to good outcomes for children. Practitioners who are overwhelmed will struggle to think, understand and make good decisions (Brandon, 2010).

Less immediately obvious but equally signifi cant is the organisational culture within which staff work and the specifi c organisational supports available to them to enable and enhance their capacity to perform at high levels. Poor organisational culture and support can undermine the best eff orts of individual service providers.



As greater emphasis is placed on a shared responsibility for protecting children, it will be increasingly important that organisations not just focus on the narrow responsibilities of their staff but create environments which authorise and actively support collaborative work. Organisational commitment to sharing responsibility that attends to shared values, knowledge and skills will assume greater signifi cance within the service system.

Sometimes this shared responsibility will be about working with Child Protection when there are serious problems about the safety and care of children. At other times, this shared responsibility will require organisational commitment to collaboration to support early intervention and a strengthened approach to earlier work with vulnerable families.

Aptitudes: messages for practice Reviewed cases reveal: process driven practice shaped by organisational requirements and constraints together with formulaic service planning undermine the ability to protect children and off er help to vulnerable families.

• Th e underpinning of all good practice and service delivery rests in the aptitudes and competence of each practitioner and service provider.

• Professional commitment to making a diff erence for vulnerable children is a key aptitude necessary to enliven the organisational standards and processes which regulate practice.

• Th e work requires high level critical thinking and reasoning skills together with a focus on action. Practitioners require the aptitude to both think through problems as well as to act to address these. Lack of action, loss of momentum and drift are incompatible with eff ective practice to protect children.

• Child Protection practice requires practitioners ‘…to be curious, to be sceptical, to think critically and systematically…retain an open and questioning mindset and maintain a respectful uncertainty’ (Brandon et al, 2008). Being respectfully sceptical is crucial given that information and understanding will always be partial and family circumstances are fl uid and can change quickly.

• On the other hand, scepticism without compassion is not helpful. It is important for parents to be treated with respect and compassion whilst at the same time not losing primary focus on children (Brandon et al, 2008). Making professional judgements about safety and wellbeing does not involve being judgemental.

• Practitioners need to be able to think broadly beyond immediate concerns and events to recognise patterns over time and hypothesise about underlying causes so that eff ective protective plans can be devised.



• Th inking and acting collaboratively must be a key attribute of all involved in protecting children.

• A commitment to communication is a mindset which underpins collaborative work and guards against any assumption that ‘someone else is dealing with it’.

• A commitment to being action oriented is also an important prerequisite for the protection of children. All action should be well considered and deliberative. Some situations require the need for urgency to be recognised.

Reports to Child Protection: messages for practiceReviewed cases reveal: issues persist in relation to shared understanding across Child Protection and other services about the point at which direct Child Protection intervention should take place, particularly about identifying cumulative harm and responding early to reports of neglect.

• Th e function of intake sets the foundation of good practice.

• Receiving, interpreting and decision-making about referrals to Child Protection are core elements of practice because they determine the important question of whether or not direct statutory Child Protection intervention will occur.

• Intake into Child Protection must relate to the legal responsibility enshrined in the legislation to protect children rather than thresholds being enacted as a gateway to ration and restrict a service response.

• Whilst it is the role of statutory Child Protection to determine whether a report meets the threshold of concern for direct intervention, Child Protection should work with the local network of services within which it operates to build greater agreement about the threshold requiring a direct statutory response. It is important that there is confi dence about how the intake function of Child Protection operates to screen referrals either in or out of the system.

• Professionals who make reports to Child Protection should receive feedback about what action will be taken. Professionals should always get a response about their referral.

• Information received in reports should be objectively assessed and screened taking into account the full scope of available information rather than privileging information which supports a view that intervention is not necessary.

• Whilst wide-ranging information may be collected to assist in determining whether the eligibility threshold for direct Child Protection involvement



has been met, this initial assessment for the purpose of determining an intake decision is not the same as undertaking a comprehensive assessment.

• Eff ective Child Protection practice is ‘front end intensive’. Careful, detailed and thorough w

996 vcdrc annual report 2012 - parliament.vic.gov.au · th e victorian child death review committee...

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