This report considers a small cohort of children known to the child protection system who died from medical conditions, with a particular focus on systemic factors affecting access to timely and appropriate healthcare. It identifies common system-level issues across these cases that may have compounded risk and contributed to the progression and severity of individual health issues. The Child Death Review Board (the Board) recognises that early intervention can be lifesaving; however, delays can be detrimental to survival outcomes, which highlights the critical role of early intervention and the detrimental impact of delays in care on survival outcomes.
Each case has been considered by the Board in previous thematic reviews. Across all cases, a common theme was a persistent failure: to uphold the best interests of the child as a paramount principle and to centre decision-making on the child.
This summary report will examine systemic issues arising in cases where children known to the child protection system died from medical conditions, with a particular focus on failures in timely recognition, assessment, and response to medical neglect and unmet health needs. The report will explore how delayed or fragmented interagency responses, particularly between Child Safety and health services, may have contributed to missed opportunities for early intervention and escalating risk.
The report will consider circumstances where medical conditions were treatable or manageable with timely access to appropriate healthcare, but where breakdowns in care, oversight, or coordination compounded harm. The report will centre on system-level factors influencing decision-making, information sharing, and accountability for children at heightened medical vulnerability. The review will focus on tertiary child protection and interagency system performance for children already known to services, rather than broader population-level health prevention strategies.