The following is the report Pru Goward Family and Community Services Minister referred to in the 7.30 report on Friday on Child deaths.
There obviously appears to be tension between the Minister and this department with Goward attacking the department by saying she had been misled.
Clearly, as with most of the other government department, there would be no investigation policy and anyone who complained would be fucked over by management.
Ombudsman’s Foreword
iii
NSW Ombudsman
iii
This report concerns the deaths of 77 children in 2010 and 2011. My office reviewed these deaths under my statutory
responsibilities because they occurred as a result of abuse or neglect or in suspicious circumstances, or while the children
were in care.
The report includes a specific 10-year review of teenagers who died following incidents of violence with their peers. This
work illustrates that much more needs to be done to make sure we respond effectively to young people at risk; and in part,
this means intervening early in the life of a child so that child protection concerns do not become entrenched problems in
adolescence.
Two-thirds of the children who died in 2010 and 2011 and whose deaths were reviewable were from families with a child
protection history.
Our past reports of reviewable child deaths have highlighted recurring problems in the child protection system, and this
report again identifies a lack of capacity in government and non-government agencies to respond effectively to children
at risk of harm, or risk of significant harm
Notably, the two-year period covered by our reviews coincided with the implementation of
Keep Them Safe
, the NSW
Government’s significant reform plan for child protection services. In this context, it is important to note two things
in reading the report. Firstly, many of the factors that lead to a child protection report – including domestic violence,
substance misuse and parental mental illness – are not of themselves predictors of risk of fatal assault or fatal neglect.
Secondly, the issues and observations in this report reflect a period of change and early days in reforming this state’s
approach to child protection. The report describes a range of initiatives that have been, and are being, put in place to meet
the challenges we have identified in a more comprehensive way than we have seen before.
It is our hope and expectation that completed reforms will result in demonstrable improvements in the capacity and
performance of agencies with child protection responsibilities. It would be particularly concerning if, in two years time,
we were unable to report that the reforms had been translated on the ground into significantly better outcomes for more
vulnerable children and families.
Bruce Barbour
Ombudsman
v
NSW Ombudsman
v
Contents
Ombudsman’s Foreword
....................................................................................................
iii
Executive summary
.............................................................................................................
1
Recommendations
...............................................................................................................
7
1.
Introduction
....................................................................................................................
9
1.1
Reviewable child deaths
.....................................................
.........................................................................................
9
1.2
The purpose of reviews
......................................................
..........................................................................................
9
1.3
Other reviews or investigations of child deaths
...........................................................................................................
9
1.4
Child protection in NSW:
Keep Them Safe
................................................................................................................
10
1.5
About this report
..............
...........................................................................................................................................
11
2.
Children who died in 2010 and 2011
..........................................................................
14
2.1
Age and gender of the children
.....................................................
............................................................................
14
2.2
Aboriginal and Torres Strait Islander status
...............................................................................................................
15
2.3
Child and family circumstances
......................................................
...........................................................................
16
2.4
Child protection history
.....................................................
.........................................................................................
16
2.5
Deaths resulting from, or suspicious of, abuse
.........................................................................................................
17
2.6
Deaths due to neglect, or suspicious of, neglect
......................................................................................................
17
2.7
Children who died while in care
......................................................
...........................................................................
18
2.8
Coronial and criminal status
.....................................................
.................................................................................
18
3.
Abuse-related deaths of children
...............................................................................
19
3.1
The children who died in 2010 and 2011
...................................................................................................................
19
3.2
Abuse-related deaths within the family in 2010 and 2011
.........................................................................................
20
3.3
Themes and issues: abuse-related deaths of children within the family
..................................................................
24
3.4
Teenage homicides
..............
......................................................................................................................................
24
4.
Peer-related homicides 2002 - 2011
...........................................................................
25
4.1
About the young people who died
............................................................................................................................
25
4.2
The offenders
.............................................................................................................................................................
26
4.3
Relationship between victim and offender
................................................................................................................
27
4.4
Circumstances of peer homicides
.............................................................................................................................
27
4.5
Risk factors and involvement with agencies: victims
................................................................................................
28
4.6
Risk factors and involvement with agencies: offenders
............................................................................................
29
4.7
Observations arising from our review of peer homicides
.........................................................................................
30
5.
Neglect-related deaths of children
.............................................................................
32
5.1
The children who died in 2010 and 2011
...................................................................................................................
32
5.2
Cause and circumstances of neglect-related deaths in 2010 and 2011
..................................................................
33
5.3
Family and carer characteristics and involvement with agencies
............................................................................
34
5.4
Themes and issues: neglect-related deaths of children
...........................................................................................
37
6.
Children who died while in care
.................................................................................
38
6.1
Children in care who died during 2010 and 2011
......................................................................................................
38
6.2
Causes of death
.....................................................
....................................................................................................
39
6.3
Themes and issues: deaths of children in care
.........................................................................................................
42
1
NSW Ombudsman
1
Executive summary
Reviewable deaths of children
The death of a child 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;
•
at the time of their death, the child was in detention.
Over the two-year period from 1 January 2010 to 31
December 2011, 1170 children died in NSW. We identified
77 (6.6%) of these deaths as 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.
Half (38) of the children who died were under five years
of age, and over two-thirds were male children. Almost
one-third (23) of the children were identified as being
Aboriginal or Torres Strait Islander.
Two-thirds of the families of children who died had a child
protection history. This means the child and/or their 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.
Abuse-related deaths of children
Most of the children who died in abuse-related
circumstances were either very young, or were teenagers;
16 were aged 12 years or less, most of whom were under
six years of age. Eleven were teenagers.
The age of the children was reflected in the circumstances
of their deaths; all of the younger children died in abuse-
related circumstances within the family, and all teenagers
died in community–level incidents of violence.
Most of the teenagers (9) were killed in incidents of
confrontational violence involving a peer or peers. These
deaths are considered in the report a separate focused
review of peer-related homicides over a ten-year period to
2 011.
Abuse-related deaths within the family
In the case of children under 12 years of age, the offender
or alleged offender was either the child’s parent, or a
person in a parental or caring role to them. These deaths
occurred either in a context of intentional harm to a child,
sexual abuse of a child; or parental psychotic illness.
The families of half of the children who died in abuse-
related circumstances had a child protection history.
Families of children who died in the context of parental
psychotic illness were more likely to have had prior
involvement with mental health and drug and alcohol
services.
Information was available for 19 offenders relating to
the deaths of 14 children that occurred within the family.
‘Offender’ in this report includes both known and alleged
offenders:
•
Twelve of the 19 were known to police, and all had come
to the attention of police at some stage for domestic
violence.
•
Twelve had been previously identified in reports to
Community Services as being a person causing harm
or posing a risk to children.
•
Mental health issues were noted in the history of
ten offenders, including diagnosed mental illness or
illnesses in four cases.
•
Nine offenders had reported problems related to
alcohol and other drug use, with six identified as having
a chronic problem.
Themes and issues: abuse-related deaths
of children within the family
For children who died in abuse-related circumstances
within the family, our reviews identified:
•
Issues related to Community Services’ capacity
to respond to children who were determined
to be at risk of significant harm. This included
reports of risk of significant harm being closed
without full assessment because of competing
priorities, and risk assessment that was not fully
informed, and/or not inclusive of interviewing the
child.
•
Concerns about the adequacy of agency
identification of risks to children, particularly
in the context of parental mental illness, and
hospital presentations for physical injury of
young children.
•
Where families were involved with different
agencies, there was not always effective
information exchange and/or effective
coordination.
Peer-related homicides 2002 - 2011
Nineteen young people aged between 14 and 17 years
died between 2002 and 2011 in incidents involving a
peer(s).
The victims
Most (16) of the young people who died were male and
three were female. Four victims were Aboriginal, and
nearly one-third (6) of the victims were identified as
coming from other culturally and/or linguistically diverse
backgrounds.
Just over half of the victims were friends or social
acquaintances of the offender. The most common
scenario in which young men died involved an altercation
with another young male(s),
2
Report of Reviewable Deaths in 2010 and 2011
|
Volume 1: Child Deaths
|
March 2013
arising at social gatherings, and in a small number of
cases, the incidents appeared to be linked with ‘gang’
rivalry. Other scenarios included unprovoked attacks and
fatal injuries sustained while handling guns.
More than one-third (7) of the victims were known to
multiple agencies as vulnerable or ‘at risk’ adolescents.
Typically, these agencies included police, Community
Services, health, Juvenile Justice and education
authorities, as well as other support services.
The offenders
Thirty-one persons were identified as offenders in relation
to the 19 deaths. Offenders ranged in age from early
teens to young adults in their twenties. Just over half were
aged 14 to 17 years at the time of the incident. All but one
offender was male. Six offenders were Aboriginal, and
seven were from culturally and/or linguistically diverse
backgrounds.
Overall, offenders had a high level of prior involvement
with police. This contact ranged from relatively minor
incidents – for example, fare evasion – to significant
contact comprising multiple arrests and charges for
offences including violence.
Seventeen of the 31 offenders had a documented history
of alcohol and/or other drug use. In ten of these cases,
records indicated significant and chronic substance
abuse.
Half (15) of the 31 offenders had, at some point in their
lives, been identified as children or young people at risk.
Ten had been the subject of a report of risk of harm or
risk of significant harm to Community Services during
the three years prior to the offence, and five had earlier
histories.
Observations arising from our review of
peer homicides
Notable issues identified through our review of peer-
related homicides were:
•
Victims and offenders often had similar profiles. A
significant number of young people, whether victims
or offenders, were involved in risky or dangerous
behaviour, including drug and alcohol misuse, offending
and other anti-social behaviour.
•
Alcohol and/or drug use was common amongst victims
and offenders – both in terms of a documented history
of misuse, and as a possible factor relevant to the
circumstances of the fatal incident.
•
Many of the victims and offenders had previously come
to the attention of police for risk-taking, and violent or
anti-social behaviour, highlighting the critical role of
police in providing a coordinated interagency response
to this cohort.
•
Offenders frequently left school early, and before
completing high school. The importance of this issue is
emphasised by recent legislative change to expand the
statutory grounds for reporting risk of significant harm
to include educational neglect and cumulative harm,
as well as a government initiative to raise the school-
leaving age in the NSW.
•
For most young people, reports of risk of harm did not
elicit a comprehensive response. This was generally
because of competing priorities, but also because of
the challenges of effectively engaging young people.
Neglect-related deaths of children
Between 1 January 2010 and 31 December 2011, 21
children in NSW died as a result of neglect (14), or in
circumstances suspicious of neglect (7). The large
majority of the children were very young; most (17) were
under four years of age, and over a third were infants less
than one year old.
The majority of the children (16) were male; five were
female. Over one-third of the children (8) were identified as
Aboriginal.
The families and carers
In 2010 and 2011, the majority (15) of the families of
children who died in neglect-related circumstances had
a child protection history. The issues of concern raised
in reports included child neglect, such as sub-standard
home environments, inadequate supervision, and families
failing to engage with needed services. Reports for
families commonly raised concerns about parental drug
abuse and domestic violence.
Seven families had some involvement with police, relating
to offending behaviour. Five of these families had an
extensive history, primarily for drug and/or alcohol related
offences and domestic and other violence.
Families were mostly involved with health services related
to antenatal and early childhood services, and drug and
alcohol treatment. These services in the main did not
consistently identify child protection concerns.
Cause and circumstances of neglect-
related deaths
The majority of the children (14) died in the context of a
significantly careless act on the part of a carer. Nine of
the 14 children died suddenly and unexpectedly in sleep
environments that were unsafe, including five infants
who died while co-sleeping with adults. Two children
died in motor vehicle crashes. One child drowned and
two other deaths were caused by heat exposure and
smoke inhalation. In half of the 14 cases, the deaths were
considered neglect-related in part due to the carer(s)
being, or suspected of being, affected by drugs and/or
alcohol at the time the child died.
Six children died in circumstances where there was an
intentional or reckless failure on the part of a carer to
adequately supervise the child. All six children drowned. A
common scenario – both in this reporting period and over
the nine years of reviewing neglect related deaths – is the
3
NSW Ombudsman
drowning death of a very young child unsupervised for a
relatively long period of time,
and
where carers were aware
of defects in barrier fencing and the capacity of the child
to access water.
One child died as a result of a failure on the part of carers
to provide adequate medical care and assistance.
Themes and issues: neglect-related
deaths of children
Notable issues for the families of children who died in
neglect-related circumstances were:
•
Where child protection reports relating to neglect
reached the threshold of significant harm, they were
often unable to be assessed due to more urgent
demand for statutory intervention at the local level.
•
While early intervention services were a potential
support for families, we identified some problems with
families being deemed ineligible for assistance, and
in some cases, with services being withdrawn from
families because of lack of engagement on the part
of parents.
•
The most commonly identified issue of concern in
families where a child died in circumstances of fatal
neglect was parental alcohol or drug misuse.
Children who died while in care
Between January 2010 and December 2011, 29 children
who died in NSW had been living in care. Twenty-one of
the children were in out-of-home care because of child
protection issues, and eight of the children were placed in
disability accommodation services.
Most of the children in care who died were either very
young or were adolescents. The majority (16) were
children under 10 years of age, and 11 were aged 15-17
years. Two thirds of the children were male. Eight children
were Aboriginal and one child was Aboriginal and Torres
Strait Islander; this reflects the number of Aboriginal and
Torres Strait Islander children in the NSW out-of-home
care population (34%).
The majority (23) of the 29 children had a child protection
history, including five children who were in voluntary care.
For some children, the child protection history preceded
and was the reason for their entry into care; however
12 of the children were the subject of one or more child
protection report while they were in care.
Most (19) of the children in care who died in 2010 and
2011 were residing in placements provided or funded
by Community Services. Eight children were placed in
a disability accommodation service. One infant died in
hospital without ever being discharged following birth,
and one young person was homeless.
Causes of death for children in care
Half (15) of the children in care died as a result of
natural causes, often related to significant disabilities or
congenital or degenerative disorders. Eight children died
as a result of unintentional injury, including drowning and
poisoning, and one young person committed suicide.
Four children died from ill-defined causes, including
Sudden Infant Death Syndrome. In two cases, information
was not available about cause of death.
Themes and issues: deaths of children in
care
Notable issues arising from our reviews of the deaths of
children in care were:
•
The significant challenges for agencies in engaging and
responding effectively to children with complex needs,
and the need for:
–
early assessment and intervention both before and
following entry into care; and
–
effective coordination and collaboration between
agencies working with these children.
•
In the context of the number of children who died as
a result of preventable injury, the need for agencies to
have robust policy and practice and education initiatives
for staff and carers that enhance child safety in foster
and relative/kinship care placements. Particular areas of
focus should be swimming pool safety, safe storage of
medicines and safe sleeping practices for infants.
Themes and issues: reviewable
child deaths in 2010 and 2011
Noting the context of reform and rapid and continuing
change in the child protection system, our reviews of child
deaths in 2010 and 2011 identified a range of themes and
issues as described below.
Responding to risk of significant harm
Community Services did not have capacity to respond
to a number of families that had been the subject of
frequent reports to the agency. In these cases, we
found that risk at times was not assessed, or not
assessed adequately because of competing priorities
and gaps in casework. In particular:
•
Reviews identified shortcomings in assessing
cumulative harm and gathering adequate information
to make an informed assessment of risk, including the
failure to interview children.
•
At times, there was poor information exchange and lack
of coordination between agencies, which presented
barriers to effective intervention with families.
•
In relation to young people, we found little evidence of
agency liaison and integrated support.
2010 and 2011 were the first two years of
Keep Them Safe
.
Reforms are also ongoing, and a number of initiatives are
currently being rolled out to improve the agency’s capacity
to respond more effectively to risk of significant harm.
4
Report of Reviewable Deaths in 2010 and 2011
|
Volume 1: Child Deaths
|
March 2013
Identifying and responding to children at
risk: health and education
Reviewable deaths of children in 2010 and 2011 raised
specific issues about support for children of parents with
mental illness, dealing with physical injury, recognising
risk in an education context, responding to young people
with complex needs, and effectively managing early
intervention.
Parents with mental illness
Mental illness has been identified through court processes
as a directly contributing factor in the fatal assault
deaths of four children in 2010 and 2011, and was a likely
contributing factor in the death of a fifth child.
Psychotic or mental illness has been identified through
criminal investigations and proceedings as a primary or
contributing factor in one-fifth (18) of reviewable child
deaths since 2003. In the large majority of cases, the
offender was the child’s parent or carer.
Many people with psychotic illness are parents. Most
function very well, but some may be impaired in their
ability to care for dependent children.
NSW Health policies relevant to parents with mental illness
underscore the importance of a focus on children, and
the identification of risks and need for family support.
However, it was apparent that mental health services were
not always cognisant of the support needs of patients as
parents, or of the possible impact of the parent’s mental
health concerns on children.
Our recommendation
We have recommended that the Ministry of Health
consider the issues raised in this report relating to
parental mental illness, and advise us about current
or proposed strategies to promote understanding of,
and an effective response to, the needs of children of
a parent with a mental illness.
Responding to physical injury
In 2010 and 2011, three children who were fatally assaulted
had been presented to NSW hospitals or private medical
services for treatment of physical injury in the months or
days prior to their death. The three children were aged six
years or younger.
Since 2003, we have identified that ten other children who
subsequently died in abuse-related circumstances were
presented to a NSW public hospital with injuries within the
months prior to their death. All of the children were aged
six years or less; nine were under three years of ages,
including three infants.
Health services deal with many presentations of children
with a range of injuries. Even where there is some
suspicion of physical abuse, formulation of forensic
opinion can be difficult. However, the importance of
accurate assessment or identification of abusive injury
when children are presented for treatment is a serious
issue.
In a prevention context, and noting the increased
responsibility health services have under
Keep Them Safe
,
valuable insight and learning could be gained from close
review of cases where children who present with injury
subsequently die in suspicious circumstances.
Our recommendation
We recommend that the Ministry of Health undertake
an internal review if a child dies in suspicious
circumstances within 12 months of receiving care or
treatment from a NSW public health facility.
Identifying risk in an education context
In 2010 and 2011, three children who died in
circumstances of abuse or neglect had a recorded history
of chronic school absenteeism.
Over the past four years, this office’s work in a number
of areas has raised issues relating to agency responses
to chronic school absenteeism. Children who experience
significant interruptions to their schooling are deprived
of a fundamental right relating to their development, and
lose the social support network and structure that the
school community can provide. There is a need for a
strong interagency approach in a child protection context,
and holistic assessment of children who have significant
school attendance issues.
A number of strategies are under way in NSW that aim
to address responses to educational neglect, including
the piloting of an early intervention program for students
below the risk of significant harm threshold who may be at
risk of educational neglect.
Managing risk through early intervention
There is a ‘service gap’ between early intervention
services and child protection.
Four families of children who died in 2010 and 2011 were
considered to be candidates for early intervention services
following a child protection report, and were referred to
them, but the families either declined a service, or were
deemed ineligible for one. In all cases, this meant that
there was no further assessment or other action in relation
to child protection concerns at that time.
Four families did engage with early intervention, but
services were withdrawn from two of the families because
they achieved limited progress in addressing entrenched
issues, or failed to participate effectively in the program.
Community Services has introduced the
Strengthening
Families program
, which provides for Community Services’
early intervention teams to work with families with more
complex needs in an early intervention context.
The NSW
government has also proposed introduction of stand-alone
orders requiring a parent or primary caregiver to attend a
parenting capacity program or other treatment or program.
5
NSW Ombudsman
Appropriate support and intervention for
young people
Our review of peer-related homicides between 2003 and
2011, and the deaths young people in care who had
complex needs, highlighted two recurring themes:
•
The need for targeted, timely and coordinated
intervention and support for young people at risk,
including young people engaging in risk-taking and
anti-social behaviour.
•
The importance of early intervention, both early in life
and ‘early in the pathway’. Reviews provided a clear
illustration of young people – both victims and offenders
– who had child protection histories early in their lives,
and/or whose behaviour indicated their psycho-social
needs were not being met as adolescents.
These themes are not new. This office’s work has
highlighted concerns about the adequacy of service
provision to vulnerable older children and young people,
including young people in care, over a number of years.
There is a broad acknowledgement across agencies of
the pressing need to improve responses to adolescents at
high risk.
Monitoring recommendations
In the context of rapid and far-reaching change for
agencies in relation to the protection of children at the time
our previous reviewable child deaths report was published
in August 2011, we made no recommendations. Instead
we provided our report to agencies with child protection
responsibilities and sought specific feedback from
relevant agencies on key issues raised, including:
•
Capacity and service improvement through
Keep Them
Safe
(including capacity to undertake comprehensive
assessment of risk to children, enhancement of the role
of early intervention services, and support for young
mothers and high needs adolescents living in care);
•
Developments in swimming pool safety measures,
particularly consideration of Coronial and Child Death
Review Team recommendations.
We received detailed information from the Department of
Family and Community Services (Community Services
and Housing NSW) and the Ministry of Health.
In relation to capacity and service improvement issues,
Community Services provided an overview of current
reforms in child protection, and capacity to undertake
comprehensive assessments for children through
initiatives including Structured Decision Making, Practice
First, and Practice Framework. The Ministry of Health
provided information about how the capacity of NSW
Health and its workers has been enhanced through
Keep
Them Safe
initiatives such as NSW Health Child Wellbeing
Units, the Mandatory Reporter Guide, capacity to share
information through Chapter 16A of the
Care Act
, the NSW
Interagency Guidelines, the appointment of NSW Health
Child Wellbeing Coordinators, Family Referral Services,
Safe Start and Whole Family Team programs.
In addition, Community Services provided advice
regarding the implementation of its Pre-Natal reports
policy and related procedures, and other programs and
initiatives within the Early Intervention and Placement
Prevention spectrum. The Ministry of Health also provided
detailed information regarding expanded early intervention
services through its
Getting On Track in Time (Got It!)
program, and Sustaining NSW Families health home
visiting program.
Housing NSW provided comprehensive information about
a number of initiatives that focus on providing housing
assistance and support to people who are homeless or
at risk, as well as details regarding the recently released
Going Home Staying Home
Reform Plan.
All three key agencies - Housing NSW, Community
Services, and the Ministry of Health – provided information
regarding the provision of support for young mothers,
particularly those who are homeless or in marginal
housing, as well as support for high needs adolescents
living in care. Agencies referred to screening, assessment,
review and intervention processes, psychological
services, and other state-wide and local-based program
initiatives such as those funded under the National
Partnership Agreement on Homelessness.
In relation to swimming pool safety, we note the significant
developments in promoting the safety of young children
around private swimming pools, including legislative
7
NSW Ombudsman
Recommendation 1:
.......................................................................................................
50
The Ministry of Health
The Ministry of Health should consider the issues raised [section 7.5], and provide advice regarding current or
proposed strategies to:
•
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.
Recommendation 2:
.......................................................................................................
51
The Ministry of Health
Noting that processes will need to be put in place to advise the Ministry of Health and Local Health Districts of the
suspicious death or injury of a child:
•
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
Report of Reviewable Deaths in 2010 and 2011
|
Volume 1: Child Deaths
|
March 2013
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
|
Volume 1: Child Deaths
|
March 2013
•
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
Report of Reviewable Deaths in 2010 and 2011
|
Volume 1: Child Deaths
|
March 2013
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
Report of Reviewable Deaths in 2010 and 2011
|
Volume 1: Child Deaths
|
March 2013
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.
change, highlighting information drawn from the NSW
Child Death Review Team’s work and recommendations in
this area
No comments:
Post a Comment