Report

Lost, not forgotten

Inquiry into children who died by suicide and were known to child protection

13 Nov 2019
Description

This inquiry provides an important opportunity to reflect upon service provision in the context of a child taking their life. However, it is essential to be clear about its limitations:

First, this is an inquiry that is primarily focussed on examining the quality and effectiveness of Child Protection and child and family services delivered (or omitted to be delivered) to 35 children, many of whom had been known by Child Protection since early childhood, and the extent to which these services responded to their changing and often significant needs. The services delivered (or omitted to be delivered) to these children occurred in the context of reported abuse or harm and rarely as a result of these children being identified as at risk of suicide.

Second, the child death inquiries reviewed span a 12-year period, between 1 April 2007 and 1 April 2019. During this time, the landscape has changed significantly. The Commission has exercised careful judgment in balancing the need to honour the experiences of all 35 children, while maintaining a measured focus on exploring systemic issues raised in more recent child death inquiries conducted in the last five years (n=15).

Third, the constellation of events and characteristics that came together in these cases to produce an outcome of fatality cannot be distilled into a check list of predictive risk factors. The nature of harms experienced by these 35 children and the corresponding level and frequency of exposure, makes them in some ways indistinguishable from other children in contact with the child protection system. In most cases with similar characteristics and experiences, however, a child will not come to such catastrophic harm. Yet there are still opportunities to learn from the lives of these 35 children and the points at which service intervention may help to contain these risks.Fourth, this inquiry does not examine in detail the quality and effectiveness of mental health services delivered to these children. The Commission for Children and Young People Act 2012 (CCYP Act) does not provide the Commission with jurisdiction to review the appropriateness or otherwise of clinical-decision making by a registered health or mental health practitioner. The Commission has focussed instead on identifying the points and scope of mental health service delivery, and its intersection with the child protection system.

Fourth, this inquiry does not examine in detail the quality and effectiveness of mental health services delivered to these children. The Commission for Children and Young People Act 2012 (CCYP Act) does not provide the Commission with jurisdiction to review the appropriateness or otherwise of clinical-decision making by a registered health or mental health practitioner. The Commission has focussed instead on identifying the points and scope of mental health service delivery, and its intersection with the child protection system.

Fifth, it is important to acknowledge the limitations inherent with any review process that seeks to examine the quality and effectiveness of services being delivered to children, without hearing from children themselves. Where available, this inquiry has sought to capture and prioritise the voices and recorded experiences of the 35 children.

Main findings:

  1. Statutory child protection – episodic risk assessments that focussed on imminent harm
  2. Child FIRST and family services – ineffective early intervention
  3. Statutory child protection – lack of child-focussed practice
  4. Ineffective early intervention
  5. Inadequate information sharing and collaborative practice
  6. A shared responsibility for suicide prevention
Publication Details
Identifiers: 
isbn: 
978-0-9945296-9-5
Language: 
English
Published year only: 
2019
612
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