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A systems review of individual agency findings following the death of a child

On 11 June 2016, 21 month old, Mason Jet Lee died in the north Brisbane suburb of Caboolture.

Before his death, Mason and his family had been known to the Department of Communities, Child Safety and Disability Services (Child Safety Services) and had presented for treatment at a Queensland hospital. Immediately following his death, the media reported extensively on the injuries and violence experienced by Mason before his death and detailed a series of concern reports being lodged with Child Safety Services.

The Queensland community, understandably, wanted to know what more could have been done to keep Mason safe and what changes needed to be made to protect other vulnerable children in Queensland.

When a child known to Child Safety Services dies, Child Safety Services is required by legislation to review their actions and decisions in relation to that child’s care and protection prior to their death. Queensland Health, under legislation, is also able to instigate its own formal review. Reviews like these are vital to determine whether there were systems failings and whether changes must be made to better respond to the protection and safety needs of a child.

In July 2016, the Premier wrote to the Queensland Family and Child Commission (the QFCC) requesting oversight of individual agency reviews of the service delivery to Mason and his family prior to his death.

The QFCC worked with both Child Safety Services and Queensland Health to ensure their reviews were timely, thorough and able to deliver outcomes to improve service delivery to vulnerable children in Queensland.

Both departments provided copies of their internal and external review reports to the QFCC for analysis and consideration.

To guide the QFCC’s review, the following terms of reference were developed:

  • Review the legislation, governance frameworks and methodologies for agency reviews to ensure they are thorough, effective and impartial.
  • Review the application of internal and external agency review processes for Mason to ensure the review is prioritised.
  • Review the information, findings and recommendations of individual agencies to provide oversight and identify trends and opportunities for whole-of-system recommendations, particularly those related to information sharing.

This report, A systems review of individual agency findings following the death of a child (the report), details the QFCC’s analysis and findings following our consideration of individual agency reviews.

The report identifies opportunities for the child protection system and child death review mechanisms adopted in Queensland to be strengthened and improved. These opportunities were condensed into a single recommendation included in the report:

That the Queensland Government considers a revised model for reviewing deaths of children ‘known to the child protection system’ (s. 246A (1)(a–d) of the Child Protection Act 1999).

This model will be designed by the QFCC in consultation with Directors-General from the nominated agencies, and be endorsed by the Interdepartmental CEO Committee.

Amendments to the Child Protection Act 1999 to transfer responsibility for the Child Death Case Review Panel to an independent government agency will be required  The review of the Child Protection Act 1999 will also provide an opportunity to reconsider the functions of the Child Death Case Review Panel in consultation with the nominated agencies.

As part of designing a revised model for child death case review, best practice benchmarks and experiences of other Australian jurisdictions should be reflected as identified by the QFCC.

Legislation will be required to compel nominated agencies who have provided service delivery to the child to undertake an internal review.

Each nominated agency may be required to:

  • establish an internal process for reviewing their involvement with children ‘known to the child protection system’. These reviews should promote learning and analysis of internal decision‑making, consideration of systems issues and collaboration with other agencies
  • initiate this process whenever a child known to the child protection system and the agency dies
  • provide the agency responsible for Child Death Case Review Panels with the terms of reference for the internal reviews, and a copy of the internal review reports, including any findings and recommendations
  • report regularly to the agency on progress in implementing any recommendations.

The revised model should also consider the giving the Child Death Case Review Panel members the additional capacity of undertaking own motion reviews (based on their own expertise and observations of what is needed). This would enable the Panel to identify trends in all child deaths in Queensland and complete a review into service delivery to prevent future deaths.

The QFCC looks forward to working with our partner agencies and stakeholders, with support from the Queensland Government, to establish a contemporary, best practice child death review model for Queensland.

A systems review of individual agency findings following the death of a child
Last modified: 
28 March 2018