Annual report of inquiries into the deaths of children ...library.bsl.org.au/jspui/bitstream/1/4185/1...Victorian Child Death Review Committee ix Contents 1 Introduction 1 2 Th e Victorian

Annual report of inquiries into the deaths of children known to Child Protection 2013Victorian Child Death Review Committee

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Published by Commission for Children and Young People, Melbourne, Victoria, Australia.June 2013© Copyright State of Victoria, Commission for Children and Young People, 2013.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.ccyp.vic.gov.au/vcdrc

Annual report of inquiries into the deaths of children known to Child Protection 2013Victorian Child Death Review Committee

Victorian Child Death Review Committee v

Foreword

Th is is the eighteenth and fi nal annual report of the Victorian Child Death Review Committee (VCDRC).Th e committee concluded operation at the end of February 2013 in the context of the establishment of the Commission for Children and Young People on 1 March 2013. Th e function that had been performed by the VCDRC since 1995 then transferred into the Commission for Children and Young People.Th is change was recommended by the Protecting Victoria’s Vulnerable Children Inquiry (January 2012) and was subsequently endorsed by the Victorian Government which had previously supported the establishment of such an independent commission. Th e establishment of the Commission for Children and Young People aims to strengthen the oversight of Victoria’s system for protecting vulnerable children, including the establishment of a fully independent child death review system.Th e work of the VCDRC over the past 18 years has sought to contribute to learning, service innovation and a culture of improvement within Child Protection and the range of other services which play a role in the protection of children. Th e contribution of the committee over time has been based on the expertise of its multidisciplinary, cross-sector membership which has enabled a broad perspective to the identifi cation of issues and changes required to address these.In line with the direction recommended by the Protecting Victoria’s Vulnerable Children Inquiry and the subsequent Government directions paper Victoria’s vulnerable children, our shared responsibility (May 2012), the outgoing committee anticipates the establishment of a revised multidisciplinary review process to examine deaths of children known to Child Protection within the newly established Commission for Children and Young People. Th is is particularly relevant within the broad policy context of a strengthened commitment to a shared responsibility for the protection of children.On behalf of the VCDRC, I off er condolences to the families, carers and friends of those children whose deaths have been considered by the committee over the duration of its operation, including during this fi nal reporting period.Th e endeavours of the many professionals who provide support and assistance to these children and families are also acknowledged. Although deaths of

Annual report of inquiries into the deaths of children known to Child Protection 2013vi

children known to Child Protection are rare events in terms of raw numbers, all are sentinel events which warrant examination and identifi cation of lessons for improving practice and service delivery to children and their families. Whilst the work of the committee has focussed on discerning key issues for improvement and service development, it has also provided insight into the complex issues which Child Protection and related services face in seeking to safeguard and improve the lives of vulnerable children. Th ese services undertake important work on behalf of the community.In this annual report, the committee has focussed on two elements of practice and service delivery – skilled assessment and services working together. Child Protection work is undoubtedly challenging and complex. However, skilled assessment and services working together are fundamental building blocks which, if well attended to, increase the likelihood of successful outcomes. Despite broad agreement about the pivotal importance of skilled assessment and services working together, defi ciencies in practice and service delivery relating to these two key aspects continue.Th e committee considers that it is vital to recognise these two building blocks of good practice as interdependent. Skilled assessment cannot occur without services reaching out beyond narrow service parameters to work with each other. Problems which result in children suff ering abuse and neglect cannot be overcome without services working together to assist and confront families about issues relating to the adequacy of their parenting. Given the foundational importance of these two elements of practice and service delivery, the committee has chosen in its fi nal reporting period to reprise longstanding problems relating to achieving skilled assessments and services working eff ectively together. Improvement remains essential in translating agreed knowledge into functional knowledge – that is, translating long agreed principles into action which is routinely refl ected in daily practice and service delivery.I take this opportunity to thank my current colleagues on the committee as well as all those who have been members since the VCDRC’s inception. Th e majority of members gave their time voluntarily to the work of the committee which required substantial monthly time commitment in already busy schedules. On behalf of the VCDRC, I hope that the information in this report and the body of work undertaken by the committee since 1995 has been useful to all those involved in the protection of children.

Carol Reeves Chairperson Victorian Child Death Review Committee, 2013

Victorian Child Death Review Committee vii

Many contributed to the work of the VCDRC and the preparation of this report.

Th e Inquiries and Review Unit within the previous Offi ce of the Child Safety Commissioner oversaw the preparation of child death inquiries and provided source material to the committee for its consideration. Staff within this unit either conduct child death inquiries themselves or work with experienced external practitioners to undertake this task. Th e ability to discern issues and associated learning is dependent upon the quality of these fi rst level reviews. Th e VCDRC appreciates the hard work and professionalism of all involved in this work.

Th e committee also expresses its appreciation to the many practitioners across numerous service types working with vulnerable children and their families, together with Child Protection staff who have participated in child death inquiries.

Th e Department of Human Services receives the outworkings of the committee’s considerations. It is also important to acknowledge the work of staff who have engaged with the material produced by the committee in order to translate learnings into action.

Finally, over the term of my appointment as chairperson, I have been assisted by two part-time Executive Offi cers from within the Offi ce of the Child Safety Commissioner who have provided administrative support to the committee – Ms Karen Elford and Ms Loula Dounias. I thank them for the considerable support they have provided.

Acknowledgements

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 2012 11

4 Analysis of child deaths from 1996–2012 15

5 Child death inquiries reviewed by the VCDRC in 2012–13 29

6 Th e w ork of the VCDRC in review: 1995–2013 45

References 52

Legislation 53

Glossary and abbreviations 54

Appendix 1 VCDRC recommendations 2012–13 56

Victorian Child Death Review Committee 1

1. Introduction

Th is is the fi nal annual report of the Victorian Child Death Review Committee (VCDRC), an external, multidisciplinary ministerial advisory body. Since its inception in 1995, the VCDRC has prepared an annual report tabled in parliament to provide for a transparent and accountable response to deaths within the Child Protection population.

Consistent with previous annual reports, this 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 2012 and February 2013. 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 2013 annual report is structured as follows:

• Section 2 provides an outline of the composition, role and function played by the VCDRC up until the end of February 2013 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 2012.

• 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 2012–13 reporting period. It also includes a description of child and family characteristics and an analysis of related practice and policy themes.

• Section 6 presents the work of the VCDRC in review: 1995–2013.


2.1 Victorian Child Death Review CommitteeTh e Victorian Child Death Review Committee (VCDRC) functioned as a multidisciplinary ministerial advisory body that reviewed 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 operated from 1995 until 28 February 2013 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. Th e VCDRC provided a level of independent scrutiny given that fi rst level reviews were undertaken by a series of diff erent internal departmental business or administrative units.

Since the establishment of the Offi ce of the Child Safety Commissioner in 2005, that offi ce carried a statutory responsibility to conduct child death inquiries for each death which fell within the legally defi ned scope of the child having been known to Child Protection at the time of death or within three months, and later expanded to within 12 months of death. Each fi rst level child death inquiry was subsequently considered by the VCDRC. As a second tier review mechanism, the VCDRC did not itself initiate or undertake any fi rst level investigative role in compiling material relating to child deaths but functioned as a second tier review to ensure integrity of internal reviews and to discern common issues across cases. Th e committee depended on the timeliness and quality of child death inquiry reports to undertake its work.

Th e VCDRC considered each child death inquiry report, identifi ed any issues relating to each case and, importantly, sought to identify learnings across cases. Th e committee provided 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 arose across cases.

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

Annual report of inquiries into the deaths of children known to Child Protection 20134

2.2 A window into routine practice

Th e purpose of child death reviews relating to children known to Child Protection is to promote learning.

Learning is central to practice and service system improvement. Learning that derives from routine auditing is the basis of quality assurance and continuous improvement processes.

While the ability to identify learnings is not restricted to cases in which children have died, these cases are an important cohort to examine in relation to potential learnings.

In some places, child death review processes occur in response to more restricted circumstances such as deaths relating to abuse. Th is is not the case in Victoria where child death inquiries are not limited to cases of perceived 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.

In Victoria, the process of child death inquiries is essentially an audit of case practice and service provision triggered by each death regardless of cause.

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, between 1995 and 2013, child death reviews were undertaken in relation to all deaths that fell within the legally defi ned scope. Th is approach meant that all cases, regardless of the cause of death, were 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 ese defi nitions and intent are continued under the Commission for Children and Young People Act 2012 (s.31).

As the Victorian approach to child death reviews 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 are 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 Victorian child death review system provides a window into routine practice and contributes to fostering a learning and development culture.

2.3 VCDRC membershipDuring the period of its operation, the VCDRC’s membership has been 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 has been well placed to consider the relationships between diff erent service systems that play a role in protecting children and responding to vulnerable children and their families.

Concluding membership Ms Carol Reeves (Chairperson)Human Services Consultant

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 MillerChief Practitioner, Child Protection and Youth Justice, 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 membersMs Brenda BolandRegional Director, Victorian Department of Human Services

Membership changesIn the past year Ms Brenda Boland, Regional Director, Southern Metropolitan Region, Victorian Department of Human Services retired from the VCDRC. Th e committee would like to acknowledge the signifi cant contribution of Ms Boland which refl ected her extensive knowledge relating to Child Protection and other related services.

2.4 Child death inquiry model: 2005–2013 Th e Inquiries and Review Unit of the former Offi ce of the Child Safety Commissioner was responsible for managing the production of child death inquiry reports. Child death inquiries were conducted and reported in a standardised format which examined risk assessment, case planning, record management, service collaboration and regional contextual issues. Th e reports produced fi ndings from this investigation process. Th e fi nal inquiry reports were provided to the VCDRC for review along with key Department of Human Services documents and coronial documents where available. Th e VCDRC advised the Minister for Community Services of its deliberations in each case as well as trends and patterns identifi ed across cases.

In the fi nal year of operation the work of the committee continued in accordance with the following model as illustrated by Figure 2.1.


Figure 2.1

Child death inquiry model for the 2012–13 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


2.5 Other authorities involved with child deaths in VictoriaA number of other offi cial bodies were involved in relation to children who died in Victoria during the period of the operation of the VCDRC. Th ese other offi cial bodies, as outlined below, will continue to play their distinct and specialised roles into the future.

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 Commission for Children and Young People (prior to the establishment of the Commission for Children and Young People this notifi cation was made to the Offi ce of the Child Safety Commissioner). Th is death is then entered onto that offi ce’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 2012

Th is chapter presents information relating to the deaths of children known to Child Protection which occurred during the calendar year 2012 and presents some quantitative data relating to these deaths.

During 2012 the Department of Human Services notifi ed the then Offi ce of the Child Safety Commissioner of 28 child deaths occurring in the calendar year January–December 2012 which were in scope for child death inquiries to be conducted.

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.

At the conclusion of the committee’s operation at 28 February 2013, no child death inquiries have been completed in relation to these 28 deaths and consequently none of these deaths have been the subject of review by the VCDRC.


Table 3.1

Deaths of children known to Child Protection in 2012 (N= 28)

Case no.

Age at death Category of death Locality

1 1 month Acquired/congenital illness Rural

2 1 month Acquired/congenital illness Rural

3 2 months Pending determination* Metropolitan

4 2 months Acquired/congenital illness Metropolitan



7 4 months Pending determination* Rural

8 7 months Unascertained Metropolitan

9 8 months Acquired/congenital illness Metropolitan

10 1 year Accident Rural

11 1 year Pending determination Metropolitan

12 3 years Acquired/congenital illness Metropolitan



15 6 years Accident Metropolitan





20 14 years Acquired/congenital illness Rural

21 15 years Suicide Rural

22 15 years Drug related Rural

23 15 years Pending determination Rural




27 16 years Suicide Metropolitan


* pending determination by coroner but information suggestive of SIDS


Category of death 2012Table 3.2

Deaths of children known to Child Protection in 2012: category of death by age (N=28)

Category 0–< 6 months

6 months–3 years

4–12years

13–17 years

Total %

Acquired/congenital illness

3 2 3 4 12 43

Accident - 1 2 3 6 21Suicide - - - 2 2 7Drug/substance related - - - 1 1 4SIDS - - - - - -Non-accidental trauma - - - - - -Unascertained by coroner - 1 - - 1 4Pending determination 4 1 - 1 6 21Total 7 5 5 11 28 100

Table 3.2 provides information on the category of death for children who were known to Child Protection and who died in 2012. Th e then Offi ce of the Child Safety Commissioner categorised 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 was relied upon when categorising each death. For those deaths not reported to the coroner, medical reports and other relevant information was used to categorise each death.

Twelve deaths (43%) in 2012 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. Six deaths (21%) were due to accidents. Th ree of the six deaths attributed to accidents involved road fatalities and three were the result of drowning. Two deaths (7%) were the result of suicide. One death (4%) was drug related.

For some deaths reported to the coroner, coronial investigations have not concluded and cause of death fi ndings remain pending. For this reason, fi gures may alter across annual reporting periods. Of the 28 deaths of children known to Child Protection in 2012, six (21%) are currently categorised as pending determination; however, this number will decrease once formal determination of the cause of death becomes known.

Th e cause of some deaths at the conclusion of the coronial process will be determined to be unascertained. At the time of preparing this annual report, the coroner had been unable to fi nally determine the cause of one death and it had been formally notifi ed as unascertainable.


Age and gender of children who died in 2012Table 3.3Deaths of children known to Child Protection in 2012: age and gender (N= 28)

Gender 0–< 6 months

6 months–3 years

4–12 years

13–17 years

Total %

Male 3 4 5 7 19 68Female 4 1 - 4 9 32Total 7 5 5 11 28 100

Table 3.3 shows that of the 28 children who died in 2012, 25% were infants aged less than six months, 18% were aged between six months and three years, 18% were between four and 12 years and 39% were adolescents aged 13–17 years.

Males made up the majority of deaths in all age groups with the exception of the 0–


Th is chapter places the deaths of children known to Child Protection that occurred in 2012 in the context of an analysis of trends in child deaths known to Child Protection 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 which fall within the legislative defi nition of ‘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.

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. Whilst quantitative data is important, the 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 1996–2012


Table 4.1Total reports, investigations, substantiations, active clients and deaths known to Child Protection 1996–20122

Year Reports Investigations Substantiations Active clients3

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 29 0.742009 44,717 11,826 6,886 42,638 26 0.602010* 52,436 14,434 8,977 47,982 30 0.622011 59,282 16,979 8,838 52,723 28 0.532012 68,928 20,148 10,326 59,797 28 0.46

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

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 reports3 Active clients are defi ned as clients whose cases are open on the last day of the reporting period


Figure 4.1Deaths of children known to Child Protection 1996–2012 (N= 353)

0

5

10

15

20

25

30

35Impact of legislative change

19 16 11 17 25 12 32 13 16 11 18 16 22 23 2325 26

6

73

55

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 2010 was notified to the Child Safety Commissioner in 2012

2010* 2011 201220092008200720062005200420032002200120001999199819971996

Figure 4.1 shows all deaths of children known to Child Protection from 1996 to 2012. 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 2007–2012. 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 1996–2012Figure 4.2Deaths of children known to Child Protection 1996–2012: category of death (N= 353)

0

5

10

15

20

25

30

35Impact of legislative change

2010 2011 201220092008200720062005200420032002200120001999199819971996

Category of death ’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10* ’11 ’12 Total %Acquired/congenital illness 4 5 3 5 11 5 9 5 4 4 10 8 10 11 6 13 12 125 35

Accident 1 3 4 4 4 4 9 3 3 1 4 5 4 2 8 4 6 69 20SIDS 6 2 1 2 - 2 8 1 2 1 3 3 5 3 5 1 - 45 13Non-accidental trauma 3 3 - 3 3 - 2 2 3 1 - 1 1 4 2 - - 28 8

Drug/substance related 3 2 2 1 4 - 1 1 2 - - - 2 1 3 2 1 25 7

Suicide/self-harm 1 1 - 1 1 1 - 1 - 2 - 1 5 2 2 2 2 22 6Unascertained 1 - 1 1 1 - 1 - 1 2 1 4 - 2 4 3 1 23 7Pending determination/not known

- - - - 1 - 2 - 1 - - - 2 1 - 3 6 16 4

Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 30 28 28 353 100

*A death which occurred in 2010 was notifi ed to the Child Safety Commissioner in 2012


Figure 4.2 shows that between 1996 and 2012, the largest category of death among children known to Child Protection was acquired/congenital illness, accounting for 125 cases (35% 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 69 deaths (20%). Of the 69 deaths attributed to accidents, 30 involved road fatalities, 17 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 2012, there were 45 deaths (13%) 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 2012, 28 deaths (8%) 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 2012, the deaths of 25 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 22 adolescent deaths (6%) were categorised as due to suicide/self-harm/risk-taking behaviour.

Between 1996 and 2012, 16 deaths (4%) were categorised as cause of death not known or pending determination. Th is includes deaths that are awaiting a coronial outcome. In a further 23 cases (7%) 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 1996–2012Figure 4.3Deaths of children known to Child Protection 1996–2012: age (N= 353)

0

5

10

15

20

25

30

35

2010 2011 201220092008200720062005200420032002200120001999199819971996

Impact of legislative change

Age ’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10* ’11 ’12 Total %0–< 6 months 6 3 3 3 6 4 13 3 5 5 10 8 8 9 10 10 7 113 32

6 months–3 years 7 4 4 7 9 2 10 5 5 1 4 6 6 9 8 10 5 102 29

4–12 years 2 2 - 3 3 2 3 2 2 - 4 4 5 2 4 2 5 45 1313–17 years 4 7 4 4 7 4 6 3 4 5 - 4 10 6 8 6 11 93 26Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 30 28 28 353 100


Figure 4.3 shows that over time, the greatest number of deaths is of infants aged between birth and six months, 113 (32%); followed by children aged between six months and three years, 102 (29%); and young people aged between 13 and 17 years, 93 (26%). Primary school age children make up the lowest number of deaths, 45 (13%).

Infants aged 0–3 years are the most represented age cluster, comprising 61% of all deaths within the known Child Protection population over time.


Gender of children who died 1996–2012Figure 4.4Deaths of children known to Child Protection 1996–2012: gender (N= 353)

0

5

10

15

20

25

30

35

2010 2011 201220092008200720062005200420032002200120001999199819971996


Gender ’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10* ’11 ’12 Total %Male 10 12 8 12 11 6 15 7 8 9 11 12 17 16 22 18 19 213 60Female 9 4 3 5 14 6 17 6 8 2 7 10 12 10 8 10 9 140 40Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 30 28 28 353 100


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 1996–2012 (N=353)

Gender 0–


Category of death by age groupings: 1996–2012 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 1996–2012: category of death by age (N= 353)

0

20

40

60

80

100

120

140

Pending determination/

not known

Unascer-tained

AccidentAcquired/congenital

illness

SIDS Suicide/self-harm

Drug/substance

related

Non-accidental

trauma

Age 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 87 24 45 22 - - 22 15 215 614–12 years 23 19 - 3 - - - - 45 1313–17 years 15 26 - 3 25 22 1 1 93 26Total 125 69 45 28 25 22 23 16 353 100


Category of death: infants (0–3 years)Figure 4.6Deaths of children known to Child Protection 1996–2012: infants by category of death (N=215)

0

20

40

60

80

100


not known

UnascertainedNon-accidentaltrauma

AccidentSIDSAcquired/congenital illness

87

(40%)

45

(21%)

24

(11%)

22

(10%)15

(7%)

22

(10%)

From 1996 to 2012, there were 215 deaths in the 0–3 age group, which makes up 61% of the total number of deaths. Of the 215 infant deaths, 113 (53%) were younger than six months.

Of the 215 deaths in the 0–3 age group, the most common category of death is acquired/congenital illness, comprising 87 deaths (40%). Th e second largest category of death among infants is SIDS. Between 1996 and 2012, 45 (21%) infants died from SIDS.

Over the 18 year reporting period, 24 (11%) of the 215 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 2012, 22 infants (10%) 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 2012, 22 infant deaths (10%) were classifi ed as unascertained by the coroner and 15 (7%) 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 1996–2012: primary school age children by category of death (N=45)

0

5

10

15

20

25

30


not known

UnascertainedNon-accidentaltrauma

AccidentAcquired/congenital illness

23

(51%) 19

(42%)

3(7%)

00

From 1996 to 2012, there were 45 deaths among 4–12 year olds (13% of the total deaths).

Of these 45 deaths, 23 (51%) were due to acquired/congenital illness, which includes deaths as a result of a disability, malignancy or acute infection.

Nineteen deaths (42%) were categorised as due to accident in this age group, with drowning and road accidents the most common causes.

Th e remaining three deaths (7%) in this age group were due to non-accidental trauma.


Category of death: adolescents (13–17 years)Figure 4.8Deaths of children known to Child Protection 1996–2012: adolescents by category of death (N=93)

0

5

10

15

20

25

30

Unascertained Pendingdetermination/

not known

Non-accidental

trauma

Acquired/congenital

illness

Suicide/self-harm

Drug/substance

related

Accident

26

(28%)25

(27%) 22

(24%)15

(16%)

3(3%) 1

(1%)1

(1%)

From 1996 to 2012, there were 93 deaths among young people aged 13–17 years (26% of the total deaths).

Of the 93 deaths in the adolescent age group, the most common category of death is due to accident, with 26 deaths (28%). Most of these deaths involved vehicles, including cars, trains and motorcycles.

Th e second largest category of death among adolescents known to Child Protection was drug/substance related, comprising 25 deaths (27%). Th is category includes cases where death was related to the use of intravenous drugs, inhalants, methadone toxicity and poly-drug use.

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

Fifteen adolescents (16%) died of an acquired/congenital illness. Twelve of these young people had disabilities and/or long-term serious illnesses.

Th ree adolescent deaths (3%) were categorised as due to non-accidental trauma. Th is category includes a case where a young person is missing, presumed dead.

Between 1996 and 2012 one death (1%) was classifi ed as unascertained by the coroner and one (1%) was categorised as pending determination.


Aboriginal status 2000–12Figure 4.9Deaths of children known to Child Protection 2000–2012: Aboriginal and non-Aboriginal child deaths (N=290)

0

5

10

15

20

25

30

35

2010 2011 20122009200820072006200520042003200220012000


’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10* ’11 ’12 Total %Non-Aboriginal child 20 9 28 10 16 10 17 19 24 23 27 26 26 255 88Aboriginal child 5 3 4 3 - 1 1 3 5 3 3 2 2 35 12Total 25 12 32 13 16 11 18 22 29 26 30 28 28 290 100


Because the collection of child death information regarding Aboriginal status was inconsistent prior to 2000, data are reported from 2000 onwards.

In 2011, Aboriginal children comprised 1.3% of the total number of children 0–17 years in the Victorian population4.

Figure 4.9 shows that between 2000 and 2012, there was a total of 290 child deaths, 35 (12%) of whom were Aboriginal children.

In 2012, 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. 4 Australian Bureau of Statistics


Stage of Child Protection involvement at the time of death 1996–2012Figure 4.10Deaths of children known to Child Protection 1996–2012: stage of Child Protection involvement at time of death (N=353)

0

5

10

15

20

25

30

35

2010 2011 201220092008200720062005200420032002200120001999199819971996


Stage of protective involvement ’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10* ’11 ’12 Total %Intake 1 4 3 6 6 1 4 3 4 2 4 2 4 4 5 2 4 59 17

Investigation 5 2 2 1 3 - 9 1 6 1 6 8 6 4 5 9 9 77 22Protective intervention 4 1 1 - 1 1 4 1 2 3 2 1 5 6 4 4 2 42 12Protection order 3 6 3 4 7 2 5 3 3 2 - 3 4 5 4 3 5 62 17Closed 6 3 2 6 8 8 10 5 1 3 6 8 10 7 12 10 8 113 32Total 19 16 11 17 25 12 32 13 16 11 18 22 29 26 30 28 28 353 100


Figure 4.10 shows that 136 children (39% of the 353 child deaths known to Child Protection in this period) were subject to Child Protection intake or investigation at the time of their death. Forty-two children (12%) were subject to protective intervention and 62 children (17%) were subject to protection orders. Child Protection had ceased case involvement with 113 children (32%) at the time of their death. Th ese fi gures have been updated based on a review of the data.5

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


5. Child death inquiries reviewed by the VCDRC in 2012–13

Th is section provides an analysis of child death inquiries reviewed by the VCDRC in the 2012–13 reporting period.

In view of the committee concluding its operation earlier than the full reporting period, the VCDRC’s fi nal reporting period covers a period of 11 months only - commencing in April 2012 and concluding at the end of February 2013.

In this 11 month period the then Child Safety Commissioner presented 22 fi nalised child death inquiries to the VCDRC for review. During its fi nal 11 months of operation, the committee conducted 15 reviews over seven meeting dates. At the conclusion of the VCDRC’s operation there were seven child death inquiries awaiting multidisciplinary review. Th e committee anticipated these outstanding and all future child death inquiries to be subject to revised multidisciplinary review arrangements within the Commission for Children and Young People.

Th e lesser number of cases reviewed in this reporting period refl ected the committee’s lower level of reviewing activity due to attending to other activities associated with winding up its operations.

Of the 15 child deaths reviewed by the VCDRC in its fi nal reporting period of 2012–13, nine deaths occurred in 2010 and six deaths occurred in 2011.

Th is chapter describes key quantitative child and family characteristics of cases reviewed by the VCDRC during the 2012–13 reporting period as well as signifi cant qualitative practice and service delivery themes and issues which the committee discerned during review of these cases.


5.1 Characteristics of the children and their familiesTable 5.1Child death inquiries reviewed in 2012–13 (N= 15)

Case No.

Year of death

Age at death

Category of death Locality Stage of Child Protection involvement

1 2011 3 months Acquired/congenital illness Metro Open/protective intervention

2 2011 3 months Unascertained Metro Open/investigation3 2010 5 months SIDS Cat II Metro Closed/intake4 2011 7 months Acquired/congenital illness Rural Closed/protective

intervention 5 2010 1 year Unascertained Metro Closed/intake6 2010 1 year Unascertained Metro Closed/intake7 2011 2 years Acquired/congenital illness Metro Open/Custody to

Secretary Order8 2010 2 years Accident Rural Closed/investigation9 2010 2 years Non-accidental trauma Metro Closed/intake10 2010 4 years Accident Rural Open/investigation

Reported to Child Protection after the accident causing death

11 2010 14 years Suicide Metro Open/protective intervention

12 2011 15 years Accident Rural Open/investigation 13 2010 15 years Drug related Rural Open/Interim

Accommodation Order 14 2011 16 years Drug related Metro Open/Permanent Care

Order15 2010 16 years Drug related Rural Open/Custody to

Secretary Order

Table 5.1 shows the 15 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 15 deaths reviewed:

• nine deaths (60%) involved children aged three years or younger

• four deaths (27%) involved infants younger than 12 months of age; two of these occurred in the context of unsafe sleeping

• fi ve deaths (33%) involved children aged 13 years or older

• four of the fi ve adolescent deaths occurred in the context of histories of multiple (fi ve or more) reports to Child Protection over extended periods

• four children (27%) were on Children’s Court orders at the time of their deaths


• nine child deaths (60%) were open Child Protection cases

• nine deaths (60%) occurred in Victoria’s metropolitan areas and six deaths (40%) in rural Victoria.

Table 5.2Child death inquiries reviewed in 2012–13: age and gender (N= 15)

Gender 0–


Table 5.4Child death inquiries reviewed in 2012–13: category of death by age (N= 15)

Category of death 0–


Figure 5.1Child death inquiries reviewed in 2012–13: key child characteristics by age (N= 15)

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 infants were born drug dependent

• two births featured inadequate antenatal care

• complex medical needs were key child characteristics identifi ed in six infant cases; one of these children had a limited life expectancy

• two children aged 6 months–3 years had multiple disabilities

• fi ve children had developmental delay or intellectual disability; three of these children were aged 6 months–3 years and two were adolescents

• all of the fi ve adolescents experienced signifi cant disruption to their education

• high risk behaviours were key characteristics identifi ed in all of the fi ve adolescent cases, with four of the fi ve having issues with substance use

• all fi ve adolescents experienced mental ill health.

Table 5.5Child death inquiries reviewed in 2012–13: care arrangements at time of death (N= 15)

Two parent families

Single parent families

Alternative care Homeless

Both parents

Mother Kinship care Out-of-home care placement

Did not leave birth

hospital

Homeless

40% 20% 20% 7% 7% 7%60% 34% 7%

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

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

• three of the children were in the care of a single parent

• four children were living in out-of-home care. Th ree of these children were in the care of extended family, and another was in a residential placement

• one young person was homeless

• one child spent the duration of their life in hospital due to complex medical issues.


Figure 5.2Child death inquiries reviewed in 2012–13: key parental characteristics by age of child (N=15)

0

5

10

15

20

25

Lack of formal

supports

Intergen-erational trauma

Intellectual disability

Lack of informal supports

Parental Child

Protection history

Substanceuse

Young mother atfirst child

Familyviolence

Transience/homeless-

ness

Mentalill health

Key parental characteristics 0–


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, substance use, mental ill health, a parental background of intergenerational trauma and transience or homelessness were identifi ed as the most prevalent factors in the cases reviewed. A mother aged 20 or younger at the birth of her fi rst child and a parental history of involvement with protective services as children or adolescents were also prevalent. Th e existence and co-existence of these parental characteristics occurred in families across all age groupings.

Of the 15 child death cases reviewed:

• family violence was a factor in 12 cases

• parental use of alcohol and/or drugs was evident in 12 families

• parental mental ill health was a factor in nine cases

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

• transience or homelessness aff ected seven families

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

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

• in fi ve families a parent was identifi ed as having an intellectual disability

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

• three families were socially isolated

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


Figure 5.3Child death inquiries reviewed in 2012–13: co-occurrence of parental characteristics: mental ill health, family violence, substance use and intellectual disability (N=15)

40%Predominantly family

violence and substance use or mental ill health

and substance use

27%Mainly family violence,

substance use and mental ill health

20%Family violence, substance use,

mental ill health and intellectual disability

2 risk factors 3 risk factors 4 risk factors

Again in the 2012–13 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 with thirteen (87%) of the families presenting with two or more of these risk factors:

• six (40%) of the families presented with two of these four parental risk factors, most commonly family violence and substance use

• four (27%) of the families presented with three of these parental risk factors, the most common being family violence, substance use and mental ill health

• three families (20%) presented with all four risk factors: family violence, substance use, mental ill health and intellectual disability.


Table 5.6Child death inquiries reviewed in 2012–13: services identifi ed as involved by age of child (N=15)

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 Practice and service delivery: themes and issuesAs a second tier review mechanism, a key contribution made by the VCDRC to the process of reviewing child deaths known to Child Protection was to identify common themes across the cases reviewed in each reporting period.

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

Within the Offi ce of the Child Safety Commissioner, a comprehensive case tracking system recorded 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 and across reporting periods. Numerically common client and case practice characteristics, together with dimensions of service provision, were distilled from the data set. Th is served 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 15 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 derived 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 was provided in correspondence to the Minister for Community Services and the Department of Human Services as each case was reviewed. Th e culmination of the review period enabled 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.

In this reporting period, the committee’s attention focussed on issues relating to assessment and services ‘working together’.

Th ese issues were a major feature of cases reviewed in this reporting period and have consistently featured as common themes and issues across cases that the committee has reviewed over the years of its operation.

As the committee considers that undertaking skilled assessments and services working together are the foundations of eff ective child protection practice, it is apposite in this fi nal report to emphasise the signifi cance of these two dimensions of practice and service delivery. Whilst there is no dispute about the importance of these elements as the building blocks of successful practice and service delivery, a range of basic defi ciencies continue. Th ere is a need to turn widely agreed knowledge about what is important into functional knowledge – that is, to turn understanding about what is required into action that is routinely refl ected in daily practice.

Th e recurring identifi cation of issues concerning undertaking assessments and services working together does not lessen the relevance of these issues; rather it highlights the ongoing problem of being able to successfully respond to the needs of vulnerable children if these elements are not fully attended to.

Th e committee wishes to reinforce that undertaking competent assessments and services working together are not separate dimensions of practice and service delivery; they are interdependent elements which cannot be separated.

Assessment of the safety and wellbeing of children is not possible without services working together. Working together (through processes that enable information exchange, cooperation, collaboration and agreed approaches to cohesive service provision) is not an optional extra. It is not an enhancement to minimum requirements but is integral to good practice and service provision.


Th e following observations from earlier reporting periods refl ect both that assessment and working together have been consistent themes over time and that the committee has presented these as interrelated components of eff ective practice and service delivery:

… joint planning and improved communication processes would have brought together the necessary range of services to share knowledge and allow a comprehensive assessment of parenting capacity. (2008)

Multiple service involvement…(requires) layers of information that need to be communicated within and between service systems. (2008)

Th ere needs to be wider and more thorough engagement of other services during the assessment process. (2009)

Too often there is only partial information collected from a limited number of service providers and information is superfi cial…(2009)

Too often Child Protection seeks information from other services…but does not share information with other services, even when expecting those other services to work with the family to ameliorate risk and monitor the safety and welfare of children. (2010)

A mindset of collaborative practice is required to strengthen the joint eff ort across universal, secondary and tertiary service systems. (2011)

… the importance of thinking and acting collaboratively. (2011)

Successful professional eff orts to protect children are always characterised by collaborative practice, whereas defi ciencies in collaborative practice invariably compromise (assessment), case practice, decision making and service delivery. (2011)

All professionals need to communicate with each other in such a way that mutual understanding is promoted and misunderstandings are minimised. (2011)

Th e ability of services to eff ectively engage and work with families toward securing children’s safety and wellbeing is dependent upon those services being engaged with each other. (2011)

Inadequate early assessment and decision making...about what needs to be done... can undermine the trajectory of cases, particularly if the level or intensity of service provision that is required is not identifi ed, is underestimated or is identifi ed but not acted on. (2012)

Child Protection does not (routinely) engage with other services before it withdraws, leaving confusion about roles and responsibilities regarding protective issues. (2012)


Discrete services cannot become eff ective service networks providing support to families without sharing information and clarifying how they will work together; if this does not occur services will work in isolated parallel silos or at odds with each other’s eff orts. (2012)

Th e child death inquiries reviewed by the VCDRC during this reporting period reveal a continuing gap between policy aims, program guidelines and practice standards and how these are translated into operational reality.

Th ere is substantial guidance both about what constitutes a comprehensive Child Protection assessment and in relation to expectations that services will work together. Child death inquiries reviewed by the VCDRC suggest that these expectations are not routinely met in the norms of daily practice and service delivery.

Whilst child death inquiries and VCDRC reviews often conclude that comprehensive assessments have not been carried out, Child Protection case records suggest that staff usually consider that they have undertaken adequate assessment. Th e VCDRC only concludes that assessments have been eff ectively undertaken if all elements of conducting an assessment have been competently attended to. Th e facts of how many cases evolved, as evidenced by child death inquiry analyses, too often indicate that too little assessment activity has taken place.

Recurring problems associated with undertaking assessments include: insuffi cient systematic information gathering; relying on partial information that confi rms views prematurely held; relying on narrow sources of information that eff ectively ‘cherry picks’ information that has the eff ect of confi rming pre-existing mindsets; misconstruing assessment as partial information which is privileged and not tested against other equally relevant sources of information; gathering wide information but not synthesising and analysing this into an overall case formulation that can inform a comprehensive plan of intervention and service provision; relying unduly on opinion information from other sources without seeking out and understanding the factual basis of this; relying on parental statements and claims which refute reported protective concerns without information from independent sources which tests the veracity of these statements and claims.

Undertaking assessments from a child protection perspective is a core task of Child Protection practitioners. Th is requires Child Protection to have suffi cient direct contact with parents and children as well as with other services. To formulate a protective assessment, Child Protection’s views and understandings ought be shared and integrated with those of other services to facilitate development of agreed case formulations which in turn provide the basis for joined-up service responses.


Over time diff erent terms have been used to refer to the critical need for there to be teamwork across Child Protection and the array of other services – primary, secondary and tertiary services - which all have important roles to play in contributing to the protection of children. ‘Working together’ is an umbrella term which incorporates sharing information, cooperation, collaboration, partnership and ‘joined up’ eff ort.

Working together is not about services simply adhering to procedures which compel them to communicate with each other. Th e protection of children and provision of assistance to parents with complex multiple needs requires commitment to build understanding across services and professional boundaries so that in-depth, nuanced communication and planning can take place.

To meet the challenges of contemporary Child Protection practice it is not suffi cient for communication to be one-way or for passive seeking and imparting of information. Multidisciplinary and multiagency teamwork requires shared mindsets and agreed processes which facilitate service providers systematically working together ‘… to question, to evaluate, to actively think through what practitioners can do together’ (Sidebotham 2005).

While the importance of eff ective assessment and the need for services to work together are not new themes, routinely achieving these building blocks of good practice is an enduring challenge.


Th e work of the committee over the period of its operation has sought to contribute to learning, service innovation and a culture of improvement within Child Protection and the range of other services which play a role in the protection of children.

Th is chapter looks back over the role and work of the VCDRC over the 18 year period of its operation.

External oversight of Victoria’s child death review systemAs a multidisciplinary, cross-service sector ministerial advisory committee, the VCDRC has, since its inception in 1995, provided external oversight of Victoria’s child death review system.

Initially, fi rst level reviews concerning the deaths of children known to Child Protection were undertaken internally within the Department of Human Services business unit responsible for Child Protection. Later, in 2005, responsibility for the preparation of these fi rst level reviews, known as child death inquiries, transferred to the then newly established Offi ce of the Child Safety Commissioner, an administrative unit of the Department of Human Services.

Within this context of fi rst level reviews being undertaken internally within the department responsible for the delivery of Child Protection services, the VCDRC was the mechanism that provided for external accountability and transparency.

Each year since its establishment, the VCDRC has prepared an annual report which has been tabled in parliament. Th is reported both on the number of deaths of children known to Child Protection which occurred in each calendar year as well as progressively on the learnings, individually and collectively, which emanated from these deaths as they were reviewed.

6. Th e work of the VCDRC in review: 1995–2013


Th e committee was not established or governed by legislation but operated in accordance with the following terms of reference:

• 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 three months of their death, or from 2007 within 12 months of their death, and advise the Minister for Community Services of the committee’s deliberations.

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

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

• 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.

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

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

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

Multidisciplinary overview and expertiseIn addition to the VCDRC’s external oversight function providing transparency and accountability in relation to the review of deaths of children known to Child Protection, the committee has also provided a mechanism of multidisciplinary overview which has added value to the quality of review of child deaths.

Th e contribution of the VCDRC to the quality of child death review was made possible by its multidisciplinary membership. Multidisciplinary, cross-sector input has been a feature of Victoria’s child death review process since the committee’s establishment in 1995. Th e VCDRC’s membership has been drawn from the welfare, health, police, legal and academic fi elds mirroring the many professional groupings involved in the delivery of a broad child protection system. Th is multidisciplinary membership enabled the committee to utilise a broad perspective when considering fi rst level review reports which were usually prepared from a single professional vantage point, most often a welfare perspective. Analysing and synthesising issues from a multidisciplinary, cross-sector perspective has provided a depth of understanding and learning concerning the eff ectiveness of individual services, individual service sectors and cross-service sector performance in the protection of children.


Recommendations derived from child death reviewsSince 2005, the VCDRC has made recommendations primarily directed to the Department of Human Services Child Protection program and other programs, delivered either directly or by funded services, which provide services to vulnerable families and which play a role in contributing to the protection of children. Th e committee has also increasingly commented on and made recommendations in relation to the services provided by other government departments.

Recommendations have related to the issues discerned from individual child death inquiries and common themes that have been identifi ed across cases and have focussed on identifying specifi c improvements related to these issues and themes.

Th e approach to the development of recommendations has changed over time. Up until 2005, the child death inquiry reports prepared by the Department of Human Services contained recommendations. Th e VCDRC both commented on these recommendations and made its own recommendations. Th is resulted in a burgeoning number of recommendations that did not represent a coherent approach to recommended change. In order to streamline the process and reduce and make more coherent the impost for change being suggested, a change in business rules was negotiated between the VCDRC and the Offi ce of the Child Safety Commissioner. Th is established that child death inquiry reports would specify fi ndings relating to the facts and analysis revealed by review of individual cases. Th e VCDRC, as an overview body for all child death reviews, was identifi ed as better placed to draft formal recommendations for change and further action. Th is changed approach was reported in the VCDRC’s 2006 Annual Report.

Following this change in practice concerning the formulation of recommendations, the VCDRC has translated individual child death inquiry fi ndings into formal recommendations for change as required. Recommendations made by the committee have been case-specifi c or related to common issues across clusters of cases. Th e VCDRC has adopted a prudent approach to recommendations in an attempt to have change directed toward signifi cant issues.

From 2005 to 2013, the VCDRC has made a total of 123 recommendations that have related to specifi c practice domains (for example, information gathering, assessment, high risk infants, high risk adolescents, neglect, cumulative harm, case closure practice, case conferences, partnership between services, service response to indigenous children, safe sleeping) or service sector issues (for example, health, hospitals, maternal and child health, early childhood intervention services, family support services, ChildFIRST


services, alcohol and other drug services, family violence services, mental health services, disability services, youth justice services and the interface between these numerous service sectors).

Group analyses of child deathsSince its establishment, the VCDRC has identifi ed issues from particular groups of child deaths that have warranted further investigation and research in accordance with its terms of reference.

Since the establishment of the Offi ce of the Child Safety Commissioner in 2005, this has been done jointly with that Offi ce given that the resources of the Offi ce of the Child Safety Commissioner were necessary to undertake any further investigation and research. Issues and patterns across cases have been identifi ed that require further exploration of issues and improved understandings of eff ective ways of intervening before detailed recommendations about changes to policy, practice and service delivery could be made.

Th e following Group Analyses have been undertaken informed by the work of the VCDRC:

• Connecting services: learning from child death inquiries when the co-existing parental characteristics of family violence, substance misuse and mental illness place children at risk (2012)

• Eff ective responses to chronic neglect (2006)

• Tackling SIDS – a community responsibility (2005)

• Children with complex medical needs and a limited life expectancy (2004)

• Analysis of adolescent child protection deaths (2003)6

• Partnerships in caring for children. Analysis of the intersectoral relationship between child protection, drug and alcohol and mental health services for cases of child deaths (2005)7

• Protective issues for newborn siblings of children previously taken into care (2002)

• Who’s holding the baby? Improving the intersectoral relationship between maternity and child protection services – an analysis of child protection infant deaths (2000).

6 Published as Appendix in VCDRC Annual Report 20037 Summarised in VCDRC Annual Report 2006


Dissemination of key messagesA challenge for child death review bodies is how to facilitate the key messages for practitioners being made available and being understood by the broad range of professionals who are involved in the protection of children.

Th e single recipient of Offi ce of the Child Safety Commissioner child death inquiry reports and VCDRC deliberations about these cases was the Department of Human Services which is then responsible for considering and implementing endorsed recommendations and promulgating learnings across relevant workforces. Generally, the Department of Human Services has been identifi ed as the conduit of communication concerning recommendations regarding the role played by other government departments. Overall, responsibility for the implementation of change arising from fi ndings and recommendations is the responsibility of those services toward which the advice is directed.

Th e VCDRC itself carried no role or responsibility for directly implementing change. However, the committee has played an active role in promoting its work and the knowledge that derived from its activity. Periodically, the VCDRC participated in regional information sessions about child death reviews held for Child Protection staff and other regional service providers. In addition, the committee has participated in information and training sessions by invitation.

For the past four years from 2009, alongside the preparation of each year’s Annual Report, the VCDRC has produced and disseminated brochures that have been designed to bring the work and learning outputs of the committee to a broader professional audience in a user friendly manner.


Th e brochures have summarised and distilled information for practitioners about the value of child death reviews as a learning and service improvement tool. Importantly, these documents have provided detailed practical information about specifi c areas for practice and service improvement.

Provision of advice on the child death inquiry processImplementation of the Children, Youth and Families Act 2005 in 2007 resulted in change to the previous eligibility criteria of child deaths that would be the subject of evaluation by the Offi ce of the Child Safety Commissioner through the conduct of child death inquiries and be subsequently referred to the VCDRC for review. Th e impact of this change reduced those deaths which would be in scope.

Given that Victoria already had a comparatively limited timeframe eligibility for deaths of children who were defi ned as ‘known to Child Protection’, the committee provided advice to the then Minister for Community Services advocating for the previous scope to be reinstated and for consideration of extending the timeframe eligibility to enable learnings to be derived from a broader cohort of cases.

Subsequently, the Children Legislation Amendment Act 2009 returned to scope the child death cases that had been impacted by the Children, Youth and Families Act 2005 and extended the eligibility timeframe defi ning ‘known to Child Protection’ from three to 12 months.

Future multidisciplinary input into child death reviewsTh e Protecting Victoria’s Vulnerable Children Inquiry 2012 recommended the establishment of a Commission for Children and Young People to provide independent oversight to Victoria’s system for protecting vulnerable children, including the establishment of a fully independent child death review system.

Th e establishment of the Commission for Children and Young People on 1 March 2013 saw the oversight role previously performed by the VCDRC transfer into that new body and the work of the VCDRC conclude.

Th e Protecting Victoria’s Vulnerable Children Inquiry identifi ed the need to streamline Victoria’s child death review arrangements whilst recognising the benefi t of multidisciplinary input. Specifi cally, it recommended that

‘Th e Commission for Children and Young People should convene a multidisciplinary committee such as the Victorian Child Death Review Committee to provide advice to the Commission during the course of the Commission’s inquiries into child deaths’. (recommendation 90)


Th e committee looks forward to the establishment of a revised multidisciplinary process that continues to enable multidisciplinary input to Victoria’s child death review system.


References

Cummins P, Scott D, Scales B 2012, Report of the Protecting Victoria’s Vulnerable Children Inquiry. Department of Premier and Cabinet, State of Victoria

Victorian Government May 2012, Victoria’s vulnerable children. Our shared responsibility. Directions Paper, State of Victoria

Sidebotham P D 2005, ‘Embracing Change’, Child Abuse Review Vol 14 pp 77–81


Births, Deaths and Marriages Registration Act 1996

Child Wellbeing and Safety Act 2005

Children Legislation Amendment Act 2009

Children, Youth and Families Act 2005

Documents

Annual report of inquiries into the deaths of children ...library.bsl.org.au/jspui/bitstream/1/4185/1...Victorian Child Death Review Committee ix Contents 1 Introduction 1 2 Th e Victorian