.......................................................................................................
The Ministry of Health should consider the issues raised [section 7.5], and provide advice regarding current or
Equip frontline staff in both mental health services and other health facilities, including emergency departments,
with an understanding of potential risks to, and needs of, children of a parent with a mental illness.
Ensure that a history of a patient’s children and child caring responsibilities is identified and considered in
psychiatric assessment or review.
Promote and monitor adherence within Local Health Districts to the Children of Parents with Mental Illness
(COPMI) and Safe Start guidelines and principles, particularly in relation to linking parents and families to
appropriate supports and services.
Apply and share lessons learnt from root cause analysis to inform practice and responses to parents with mental
illness across NSW health facilities.
.......................................................................................................
Noting that processes will need to be put in place to advise the Ministry of Health and Local Health Districts of the
If a child dies in suspicious circumstances within 12 months of receiving care or treatment from a NSW public
health facility, the child’s death should be the subject of internal review. The purpose of review would be to
assess whether the interaction of the child and their family with the facility raises any systems issues that should
inform future practice and service improvement at a local level and across the NSW health system.
In addition, the Ministry of Health should consider whether this process of review could be applied to
circumstances in which a child is seriously injured in suspicious circumstances within 12 months of receiving
care or treatment from a NSW public health facility.
Recommendations
9
NSW Ombudsman
1.1
Reviewable child deaths
Since December 2002, the Ombudsman has had
responsibility for reviewing the deaths of people with
disabilities in care, and of certain children.
1
A child’s death
is reviewable by the Ombudsman if:
•
the child died as a result of abuse or neglect, or their
death occurred in suspicious circumstances
•
at the time of their death, the child was in care
2
•
at the time of their death, the child was in detention.
The Ombudsman is required to report to the NSW
Parliament biennially about reviewable deaths. This report
covers the period 1 January 2010 to 31 December 2011.
In this period, the deaths of 77 children were reviewable:
•
27 children died as a result of abuse (24) or in
circumstances suspicious of abuse (3)
•
21 children died as a result of neglect (14) or in
circumstances suspicious of neglect (7)
•
29 children died while in care.
1.2
The purpose of reviews
Under Part 6 of the
Community Services (Complaints,
Reviews and Monitoring) Act 1993
, the functions of the
Ombudsman are to monitor and review reviewable deaths,
to maintain a register of these deaths, and:
•
To formulate recommendations as to policies and
practices to be implemented by government and service
providers for the prevention or reduction of deaths of
children in care, children at risk of death due to abuse
or neglect, children in detention centres, correctional
centres or lock-ups or persons in residential care (s.36
(1) (b)); and
•
To undertake research or other projects for the purpose
of formulating strategies to reduce or remove risk factors
associated with reviewable deaths that are preventable
(s.36 (1) (d)).
Consideration of how to prevent or reduce deaths of
children includes an understanding of any risk factors that
were evident in the lives of the children and their families,
and if so, whether risks or vulnerabilities were identified
and responded to.
Our reviews consider child and family involvement with
government and non-government agencies, particularly
those that have responsibilities relating to the health,
welfare and wellbeing of children. We consider any
systems or practice issues that may have directly or
indirectly contributed to the death of a child, or that may
expose other children to risks in the future; or whether
there were missed opportunities to intervene to support
families. This work involves examination of relevant
records and information relating to the children who
died, and we may also request specific information from
agencies to assist in our review.
In some cases, our reviews may highlight issues that
warrant further inquiries about the conduct of an agency.
Under the
Ombudsman Act
, we can make preliminary
inquiries for the purpose of deciding whether to investigate
the conduct of an agency, or we can move directly to
investigate an agency’s conduct in relation to the person
that died. The
Community Services (Complaints, Reviews
and Monitoring) Act 1993
also enables us to make reports
to agencies about matters related to reviewable deaths,
or issues that arise generally from our work, and to seek
information about these issues.
For child deaths in 2010 and 2011, we commenced eight
investigations and made preliminary inquiries under
the
Ombudsman Act
in relation to the deaths of seven
children. The subject agencies were Community Services,
NSW Health, the NSW Police Force and Education.
3
We
also made 23 reports to, and sought further information
from, agencies in relation to the deaths of 15 children.
Subject agencies included Community Services, Local
Health Districts, the NSW Police Force, non-government
service providers and local councils.
1.3
Other reviews or investigations
of child deaths
The NSW Coroner
Reviewable deaths are also Coronial deaths under the
Coroners Act 2009
. The role of the State Coroner is to
ensure that all deaths are properly investigated. The
Coroner may hold an inquest and can recommend
measures to prevent deaths.
The NSW Coroner also convenes the NSW Domestic
Violence Death Review Team, which is constituted
by representatives of relevant government and non-
government agencies. The Team reviews closed cases of
deaths that occurred in the context of domestic violence,
including the deaths of children.
NSW Child Death Review Team
In addition to having responsibility for reviewable deaths,
the Ombudsman is the Convenor of the NSW Child Death
Review Team (CDRT), and Ombudsman staff provide
support and assistance to the Team in its work. The
Ombudsman has had this responsibility since 2011.
1.
In
2009, the scope of the Ombudsman’s responsibilities changed in relation
to children. Prior to 2009, the Ombudsman was required
to
review the death of any child, or sibling of a child, who had been the
subject of a report of risk of harm to Community Services.
This requirement was repealed in 2009.
2.
‘In care’ in this context refers to a child under the age of 18 years who is in care as defined in section 4 (1) of the
Community Services
(Complaints, Reviews and Monitoring) Act 1993
.
3.
One investigation was discontinued. Three deaths subject to further action were subsequently determined to be not reviewable
10
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The CDRT reviews the deaths of all children in NSW.
The purpose of this work is to prevent and reduce the
deaths of children. The Team comprises representatives
from key government agencies including Community
Services, the Ministry of Health and the NSW Police
Force; two Aboriginal representatives; and independent
members who are experts in health care, research, child
development and child protection.
Community Services
The Child Deaths and Critical Reports Unit within
Community Services reviews the deaths of children
‘known to’ the agency; those children where a report was
received about the child and/or his or her siblings in the
three years preceding the child’s death.
4
A significant number of cases that are reviewed by
Community Services are also reviewable deaths. We
provide advice to Community Services about child deaths
that meet its review criteria. Community Services also
provides this office with a copy of its completed child
death reviews.
NSW Health
Under certain circumstances, Local Health Districts are
required to conduct a root cause analysis in relation
to a critical incident. This includes where a suspected
homicide has been committed by a person who has
received care or treatment from a Local Health District
within six months of the death. In some cases, this may
relate to the death of a child.
Where they have been completed, we include information
from root cause analyses in our reviews.
1.4
Child protection in NSW:
Keep
Them Safe
Child protection responses are an important consideration
in reviewable deaths. In late January 2010, significant
reforms to child protection services in NSW came into
effect with the implementation of
Keep Them Safe: A
shared approach to child wellbeing
.
5
The main goal of
Keep Them Safe
is to make child
protection a shared responsibility across government
agencies and between government and non-government
agencies, and to limit the statutory role of Community
Services to children at greatest risk. All agencies now have
prescribed responsibilities for child protection. Changes
and initiatives that have and are taking place under
Keep
Them Safe
are extensive and incorporate universal and
targeted services.
Broadly, changes related to the delivery of services to
families where children are identified as being at risk have
encompassed:
•
Raising the statutory reporting threshold to ‘risk
of significant harm’. The policy definition of risk of
significant harm is:
What is meant by “significant” in the phrase “to
a significant extent” is that which is sufficiently
serious to warrant a response by a statutory
authority, irrespective of a family’s consent.
What is significant is not minor or trivial, and may
reasonably be expected to produce a substantial
and demonstrably adverse impact on the child’s or
young person’s safety, welfare, or wellbeing. In the
case of an unborn child, what is significant is not
minor or trivial and may reasonably be expected to
produce a substantial and demonstrably adverse
impact on the child.
6
•
Introduction of new intake and referral pathways,
including:
-
The establishment of Child Wellbeing Units in key
public sector agencies (Family and Community
Services, police, education, health). The Units assist
agency staff to identify child protection concerns that
constitute risk of significant harm, and to respond
to children and families where risk is below that
threshold.
-
The establishment of Family Referral Services in the
community. These services are targeted to families
where child protection reports do not meet the
threshold of risk of significant harm, but the family
may need support. Family Referral Services assess
need and facilitate referrals to appropriate support
services in their local area. Family Referral Services
were piloted and evaluated in 2010 and 2011, and as
at January 2013, were operating in eight locations,
with planned further roll-out of 12 services.
•
Legislative amendment to permit the exchange of
information relating to the safety, welfare and wellbeing
of children between certain government and non-
government human service and justice agencies.
•
Transferring out-of-home care services to non-
government providers. The transition of statutory out-
of-home care services from Community Services to the
non-government sector is now underway and staged to
take place over the next five to 10 years.
7
At Decembe
11
NSW Ombudsman
2012, over 580 children have been transferred from
Community Services to accredited non-government
out-of-home-care providers.
8
•
Enhancing the provision of early intervention and
community based services:
-
The
Brighter Futures
program is now delivered by
non-government agencies across NSW.
-
The
Early Intervention & Placement Prevention
program, also delivered by non-government
agencies, provides support to families to address
problems before they escalate, and aims to reduce
the likelihood of children and young people entering
or remaining in the child protection and out-of-home
care systems.
•
Early intervention has been expanded to families
with more complex needs through the
Strengthening
Families
program within Community Services. Through
the program, Community Services can provide early
intervention services to families with an unborn child
or a child under nine years who is at risk of significant
harm, where parents have one of a number of issues,
and where the risk for any of the children and young
people in the family is high or very high, but they are
assessed as being safe enough to remain at home.
9
•
Establishing Aboriginal and Child Family Centres in nine
areas across NSW. The centres bring together a range
of early childhood, health and family support services
for Aboriginal families.
While the large majority of the deaths of children
considered in this report occurred after the introduction
of
Keep Them Safe
, the involvement of some of those
families who had prior contact with child protection
services spanned a period both prior to and following the
introduction of the new child protection system.
Supporting structural changes
Structural changes to child protection have been
supported by a range of related policy changes.
Community Services have, for example, introduced
Structured Decision Making tools to guide various stages
of child protection assessments, and is trialling a new
service delivery model, ‘Practice First’, that prioritises
direct work with families. The agency has also started
introducing new systems associated with workload
management and performance measurement and
monitoring.
Cross agency working groups are also considering
specific issues, including those relevant to the issues
raised in this report. For example, a state-wide
adolescents with complex needs panel, chaired by
Ageing, Disability and Home Care (ADHC), is focusing on
appropriate and coordinated responses to adolescents
with complex needs, where the current service system
has been unable to meet their needs. The panel
includes Community Services, Housing NSW, Juvenile
Justice NSW, the Department of Aboriginal Affairs, the
Department of Education and Communities and the
NSW Ministry of Health
10
In addition, the
Keep Them Safe
Senior Officer’s Group is working to develop systems for
improved agency responses to educational neglect.
11
Initiatives aimed at improving health outcomes for children
in out-of home care are well advanced. Community
Services and NSW Health Local Health Districts have
jointly implemented the
Health Screening and Assessment
Pathway
for children and young people who enter statutory
out-of-home care and who are expected to remain in care
for 90 days or more. An accommodation framework for
additional models of accommodation and support for
children with a disability, including for out-of-home care,
has been endorsed by the Ageing, Disability and Home
Care and Community Services Senior Officer Group.
12
1.5
About this report
Information sources
Under the legislation governing reviewable deaths, it is the
duty of a range of agencies to provide the Ombudsman
with ‘full and unrestricted access’ to records that the
Ombudsman reasonably requires to complete this work.
13
These agencies include the State coroner and any NSW
government department or statutory authority. The
Ombudsman can also require certain information from
agencies under the
Ombudsman Act
.
Our reviews and this report have been informed by a
range of sources, including:
•
Government agency records, from agencies including
Community Services, Health, Police and Education,
relating to children who died and associated persons.
•
Agency reports or reviews relating to the death
of a child, including internal reviews conducted
by Community Services and root cause analyses
undertaken by Local Health Districts
12
Report of Reviewable Deaths in 2010 and 2011
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•
Coronial and police information relating to the death
of a child.
•
Judgement and sentencing information from NSW
Courts.
•
For cases that have been subject to inquiry or
investigation by this office, statements of information
from both government and non-government agencies.
This report includes some trend data from 2003. In 2011,
the Ombudsman became Convenor of the NSW Child
Death Review Team (CDRT), and the functions of that
Team transferred to this office. Over the past year, we have
reviewed the capacity of the NSW Child Death Register,
and remediated data held in the register, with a view
to establishing a single register for all child deaths and
reviewable child deaths in NSW. This report has drawn on
the CDRT register for data relating to all child deaths in
NSW.
The status of cases identified as being reviewable and/or
reviewable in a particular category may change as further
information becomes available; particularly Coronial
determinations and outcomes of police investigations.
Key definitions
Reviewable death
We use the following definitions to determine whether a
child’s death is reviewable:
Abuse
Any act of violence by any person directly against a child
or young person that causes injury or harm leading to
death.
Neglect
Conduct by a parent or carer that results in the death of a
child or young person, and that involves:
•
Failure to provide for basic needs such as food, liquid,
clothing or shelter;
•
refusal or delay in providing medical care;
•
intentional or significantly careless failure to adequately
supervise; or
•
a significantly careless act.
Suspicious circumstances
Deaths are considered suspicious if:
•
There is some evidence or information that indicates the
death may have been the result of abuse or neglect.
•
Police identify the death as suspicious at the time of
the death or any time subsequent to the death and
there is some evidence that indicates the death may
have occurred in circumstances of abuse or neglect as
defined above.
14
•
The autopsy cause of death is undetermined and there
is an indication of abuse or neglect.
•
The autopsy cause of death is a treatable illness and
there is an indication that unjustified delay in seeking
treatment may have contributed to the death.
In care
A child under the age of 18 years who is in care as defined
in section 4 (1) of the
Community Services (Complaints,
Reviews and Monitoring) Act 1993
. This definition includes
children in voluntary out-of-home care and disability
accommodation services.
Child protection history
A child is considered to have had a child protection history if:
•
The child and/or their sibling were the subject of a risk
of harm or risk of significant harm report to Community
Services within the three years prior to their death; and/or
•
The child and/or their sibling was reported to a Child
Wellbeing Unit within the three years prior to their death.
Where relevant, this report may also refer to reports that
were made outside of the three year timeframe.
Homicide/domestic homicide
Homicides include cases involving a murder or
manslaughter (except in relation to transport-related
deaths), and all murder-suicides and other deaths classed
by police as homicides.
Domestic homicide is an incident involving the death
of a family member or other person from a domestic
relationship.
15
Offender
For the purposes of this report, offender is used to refer to
a person who has been convicted or charged in relation
to the death of a child (except in relation to a transport
fatality), or is suspected of involvement in the death of a
child. This includes cases of murder-suicide.
Peer
For the purposes of this report, a ‘peer’ is a young person
who is of the same or similar age and/or social grouping
13
NSW Ombudsman
Report chapters
•
Chapter 2 of this report provides demographic and
other information about the children who died in 2010
and 2011, as well as data from 2003; the first full year of
the Ombudsman’s responsibility for reviewable deaths.
•
Chapter 3 considers the deaths of 27 children that
resulted from, or were suspicious of, abuse.
•
Chapter 4 details a review of 19 teenage ‘peer’
homicides that occurred between December 2002
and 2011.
•
Chapter 5 examines the deaths of 21 children that
occurred in circumstances of neglect.
•
Chapter 6 examines the deaths of 29 children who died
while in care.
•
Chapter 7 provides a discussion of themes and issues
that have arisen from our reviews.
•
Chapter 8 discusses information received from
agencies about issues identified in our previous report
relating to child deaths in 2008 and 2009
14
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This report covers the two year period from 1 January
2010 to 31 December 2011, and relates to children who
died as a result of abuse or neglect, or in suspicious
circumstances, and children who died while in care.
Over this two-year period, 1170 children died in NSW.
16
We identified 77 (6.6%) of these deaths as reviewable.
17
As detailed in table 1, this is generally consistent with
previous years; over the nine-year period since 2003,
6 percent of child deaths in NSW have been reviewable.
The notable increase in the deaths of children in care from
2009 in part reflects the increased number of children
living in care over that period. Over the time this office
has had responsibility for reviewable child deaths, the
number of children in out-of-home care has increased by
78 percent from 10,059 children at 30 June 2003 to 17,896
children at 30 June 2011.
18
Table 1:
Children whose deaths were reviewable in NSW, 2003-2011*, number and (percent of all child deaths)
2003
2004
2005
2006
2007
2008
2009
2010
2011
Total
Child deaths in NSW
653
616
659
622
605
606
574
593
577
5,505
Reviewable child deaths
47
(7.2%)
27
(4.4%)
36
(5.5%)
35
(5.6%)
38
(6.3%)
31
(5.1%)
46
(8%)
45
( 7. 6 %)
32
(5.5%)
337
(6.1%)
Abuse-related **
circumstances
20
(3.1%)
9
(1.5%)
15
(2.3%)
13
(2.1%)
8
(1.3%)
14
(2.3%)
12
(2.1%)
14
(2.4%)
13
(2.3%)
118
(2.1%)
Neglect-related **
Circumstances
21
(3.2%)
11
(1.8%)
18
(2.7%)
18
(2.9%)
24
(4%)
13
(2.1%)
18
(3.1%)
12
(2%)
9
(1.6%)
144
(2.6%)
In care
8
(1.2%)
8
(1.3%)
4
(0.6%)
4
(0.6%)
6
(1%)
4
(0.7%)
16
(2.8%)
19
(3.2%)
10
(1.7%)
79
(1.4%)
* The deaths of four children were reviewable under more than one criteria.
** This includes deaths suspicious of abuse (12) and suspicious of neglect (48).
Percentages in this table have been rounded.
2.1
Age and gender of the children
Table 2 shows the age range of children whose deaths
were reviewable in 2010 and 2011, against the deaths of all
children in NSW. While the large majority of children who
died in NSW were infants, the largest single age grouping
for reviewable child deaths was teenagers aged 15 – 17
years, followed by children aged 1 – 4 years.
Table 2:
Number and proportion of children whose
deaths were reviewable (2010 and 2011) by
age
<1
1-4
5-9
10-14
15-17
Total
Reviewable
16
22
10
6
23
77
Not
reviewable
711
113
62
79
128
1,093
Percent
reviewable
2.2%
16.2%
13.9%
7.1%
15.2%
6.6%
Table 3 shows that half (49%) of the children whose deaths
were reviewable were under five years of age. Neglect-
related deaths were concentrated amongst very young
children, reflecting the particular vulnerability of the under-
four year age group. However, young people aged 15 to
17 years were the largest single age group in relation to
abuse-related deaths. As illustrated in table 4, this is not
consistent with previous years, and reflects an unusual
increase in teenage homicides in 2010.
Table 3:
Children whose deaths were reviewable
(2010 and 2011) by age and reviewable
status
<1
1-4
5-9
10-14
15-17
Total
Abuse /
suspicious
of abuse
3
7
4
2
11
27
Neglect /
suspicious
of neglect
8
9
1
2
1
21
In care
5
6
5
2
11
29
Total
16
22
10
6
23
77
16.
Data from the NSW Child Death Review Team 2012
NSW Child Death Register
, NSW Ombudsman, Sydney.
17.
As
noted, the criteria for a reviewable death changed in 2009. All data
relating to ‘reviewable deaths’ in this report reflects the
changed criteria.
18.
NSW Department of Community Services 2005,
Trends in the numbers of children and young people in out-of-home care in NSW
,
NSWDCS, Sydney, p.13; NSW Family and Community Services 2012,
Annual statistical report 2010/11
, NSWDFCS, Sydney, p.46.
2.
Children who died in 2010 and 2011
15
NSW Ombudsman
Table 4:
Children whose deaths were reviewable
(2003-2011) by age and reviewable status*
<1
1-4
5-9
10-14
15-17
Total
Abuse /
suspicious
of abuse
27
39
16
13
23
118
Neglect /
suspicious
of neglect
43
71
18
7
5
144
In care
16
17
11
13
22
79
Total
86
127
45
33
50
341*
*The deaths of four children were reviewable under more than
one criterion.
In 2010 and 2011, over two-thirds of the children whose
deaths were reviewable were male. As noted above, there
was an unusual peak in teenage homicides in 2010, all of
whom were male. This accounted for a larger number of
reviewable deaths of males in the 15-17 year age group,
as shown in table 5. Notably, the other nine deaths in this
age and gender group were young people living in care,
and their deaths were reviewable for this reason.
Table 5:
Children whose deaths were reviewable
(2010 and 2011) by gender and age
<1
1-4
5-9
10-14
15-17
Total
Female
7
7
6
1
3
24
Male
9
15
4
5
20
53
Total
16
22
10
6
23
77
The over-representation of males in reviewable deaths has
been consistent over the past nine years, as illustrated
in table 6. Male children aged one to four years are
particularly over-represented, with this group accounting
for one quarter of all reviewable deaths since 2003. The
majority of these children died in circumstances of abuse
or neglect.
Table 6:
Children whose deaths were reviewable
(2003-2011) by gender and age
<1
1-4
5-9
10-14
15-17
Total
Female
37
44
22
13
14
130
Male
47
82
23
19
36
207
Total
84
126
45
32
50
337
2.2
Aboriginal and Torres Strait
Islander status
In 2010 and 2011, almost one-third (23) of the 77 children
whose deaths were reviewable were identified as being
Aboriginal or Torres Strait Islander children.
Aboriginal and Torres Strait Islander children are
consistently over-represented in reviewable deaths. While
approximately five percent of the NSW population under
18 identify as indigenous,
19
on average, a quarter of
reviewable deaths each year are Indigenous children.
As table 7 also illustrates, the proportion of Aboriginal and
Torres Strait Islander children in reviewable deaths has
increased. This in part may reflect the increasing number
of children living in care; the deaths of eight of the 23
children who were Aboriginal or Torres Strait Islander were
reviewable because they died while in care.
Table 7:
Aboriginal and Torres Strait Islander status of children whose deaths were reviewable (2003-2011)
2003
2004
2005
2006
2007
2008
2009
2010
2011
Total
Not Aboriginal or
Torres Strait Islander
41
25
29
30
28
23
35
33
21
265
Aboriginal or
Torres Strait Islander
6
2
7
5
10
8
11
12
11
72
Total
47
27
36
35
38
31
46
45
32
33
16
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Over one-half of the Aboriginal and Torres Strait Islander
children who died in 2010 and 2011 were aged under five
years, as shown in table 8. Table 9 illustrates that this age
concentration is strongly reflected in deaths since 2003;
almost three-quarters of the Indigenous children whose
deaths were reviewable were aged under five years.
Table 8:
Children whose deaths were reviewable
(2010 and 2011) by Aboriginal and Torres
Strait Islander status and age
<1
1-4
5-9
10-14
15-17
Total
Non-ATSI
12
13
6
5
18
54
ATSI
4
9
4
1
5
23
Total
16
22
10
6
23
77
Table 9:
Children whose deaths were reviewable
(2003-2011) by Aboriginal and Torres Strait
Islander status and age
<1
1-4
5-9
10-14
15-17
Total
Non ATSI
63
95
36
28
43
265
ATSI
21
31
9
4
7
72
Total
84
126
45
32
50
337
2.3
Child and family circumstances
Where the children lived
Most children whose deaths were reviewable lived with
at least one biological parent. Children in care resided in
a range of situations: the most common was with foster,
relative or host families.
Table 10:
Where the child was living at the time they
died (2010 and 2011)
Child’s living situation
Number of
children
With biological parent(s)
46
With other family member(s)
2
In care
–
Foster/relative/host family care
20
–
Residential care
5
–
Biological parents
2
–
Hospital
1
–
Homeless
1
Total
77
2.4
Child protection history
A child has a ‘child protection history’ if the family – that
is, the child and/or a sibling – had been the subject of a
risk of harm report, or a risk of significant harm report, to
Community Services or to a Child Wellbeing Unit within
the three years prior to their death. This definition enables
comparison of reviewable deaths from 2003, and reflects
the State Coroner’s jurisdiction concerning the deaths of
children.
20,
21
The three-year timeframe is also aligned to
the criteria for Community Services’ internal reviews of
the deaths of children or siblings of children known to that
agency.
22
Under this criteria, two-thirds of the families of children
who died had a child protection history. This is consistent
with previous years, and is illustrated in table 11.
In 2010 and 2011, the association with a child protection
history was most apparent for children in care (23 of 29
children). While this would appear obvious, particularly
given that the care of children may have been assumed
within the three year period because of child protection
reports, it is interesting to note that 14 of the 23 children
were the subject of a report after being placed in care.
Just under three-quarters of children who died in neglect-
related circumstances and half of the children who died in
circumstances of abuse had a child protection history.
