Board’s Annual Report challenges system’s role as a parent

• Queensland’s Child Death Review Board’s Annual Report for 2023–2024 provides insights into the system responses in the 70 child death cases considered this year.
• The board this year made nine recommendations to improve Queensland’s child protection system, with a strong focus on the system’s role as a parent and how it responds to children and families in need.
• This year’s report again highlights the devastating impact of domestic and family violence on children and families, a characteristic appearing in almost 60 per cent of cases considered by the board.

Queensland’s Child Death Review Board has the challenging task of reviewing the tragic deaths of children who were known to the child protection system in the 12 months prior to their deaths, with outcomes informing actions needed to deliver better care, safety and support to families.

Of the 70 child deaths reviewed by the board in 2023–2024, 29 were from natural causes and 41 were from external causes that are considered preventable, including transport-related deaths, non-intentional injuries, suicide, unexplained deaths (sudden infant death syndrome (SIDS) and undermined deaths), fatal assault and neglect, and drowning.

The combined presence of domestic and family violence, methamphetamine use, and housing instability were again observed in a number of the board’s reviews, highlighting the high complexity we continue to see in cases and the ongoing need for intensive support to adequately respond to these families.

A key focus of this year’s annual report centred around the child protection system’s ability to perform the role of a parent and meet children’s fundamental needs beyond a placement, especially for those in residential care.

The board found residential care was unable to meet children’s fundamental needs for connection, love, safety and stability, which in many cases led to increased risk of harm and trauma, homelessness, and sexual and criminal exploitation.

The annual report makes nine recommendations for the Queensland Government, some of which echo earlier recommendations that remain unaddressed:

• Improve cross-government commitments to all children in care
• Support conversations with young people about healthy relationships and sexual and reproductive education
• Prioritise the implementation of a continuum of care for children with complex needs
• Guarantee access to mental health supports for children in care
• Improve risk assessments of children with disability and chronic medical conditions
• Coordinate health service delivery for sibling groups
• Maintain action on reducing family and domestic violence
• Enhance awareness of, and improve access to, the additional vulnerabilities of young and non-verbal children
• Strengthen child safety practice in response to parental substance and methamphetamine use

Quotes attributed to Child Death Review Board Chairperson Luke Twyford

“Each child’s death represents a heartbreaking failure of the system meant to protect them.

“The loss of life is difficult to process, but equally so is analysing the complex layers of systemic inadequacies, missed opportunities, and uncoordinated government responses that somehow contributed to these tragedies.

“Our role is to learn every possible lesson from these children’s lives and to make recommendations that can effect real systemic change and better care for Queensland children most in need of protection.

“The Child Death Review Board’s 2023–2024 Annual Report highlights clear areas for reform, including improving cross-agency coordination, increasing access to sexual and mental health and disability support, and improving safety and stability for children in care.

“For the first time, this year’s findings prompted us to challenge how the system parents a child and provides them with the love, care, security, protection and safety they need to live happy, full and fulfilling lives—sadly, our conclusion is there is still a significant amount of work to be done to give children in care the same access as those without a care experience.

“We urge the Queensland Government to act swiftly on both the new recommendations and those outstanding from previous years to prevent future child deaths and improve care and support for families in greatest need.”

For media information contact:
Kirstine O’Donnell | Queensland Family and Child Commission
Phone: 0404 971 164
Email: media@qfcc.qld.gov.au