An extract from "Reviewable Deaths Annual Report 2003-4:
An overview" Published December 2004 by NSW Ombudsman
605 children died in NSW between 1
December 2002 and 31 December 2003, and 161 of these deaths (27%) were
reviewable.
Full police and coronial information is needed for The NSW Ombudsman to undertake a detailed review of a death. This information was available for 137 of the 161 deaths. Of these deaths:
• 103 (75%) were of children where there had been a risk of harm report to DoCS for the child and/or a sibling within three years preceding their death. A total of 429 reports had been made for these deceased children or their siblings.
• 83 of the children died in circumstances related to abuse (9%), neglect (17%) or in suspicious circumstances (34%). The remainder were natural or unexpected deaths where there were no suspicious circumstances. Of the 103 children reported to DoCS, 53 died in circumstances
related to abuse or neglect, or in suspicious circumstances.
• 10 deaths were of children who died while living in care, including foster care, voluntary care and respite
care.
• 8 adolescents and one child committed suicide.
Some key findings
Assessing risk of harm
The Children and Young Persons (Care and
Protection) Act provides the statutory basis for the care and protection of children and young people in NSW and DoCS has the ‘lead responsibility’ for
providing and coordinating the community response where intervention is necessary. DoCS advised The NSW Ombudsman that in 2002/03, of 176,271 reports made to the department, 146,877 were determined to have a legal basis. These reports were made in relation to 79,612 children.
The NSW Ombudsman review of the deaths of the 103 children who had been reported to DoCS raised some key issues about risk of harm
assessment and child protection intervention:
• For 24 of the 44 children in relation to whom reports were closed at the initial assessment stage, report closure was the last DoCS action prior to the child’s death. Thirteen of the 24 children subsequently died in circumstances related to abuse or neglect,
or in suspicious circumstances.
• DoCS has a case closure policy, ‘Priority One’, which enables casework managers to allocate priority to what they consider the most urgent cases, and to close other cases. For 12 of the 37 children
in relation to whom reports were closed under Priority One policy, report closure was the last DoCS action
prior to the child’s death. These 12 children
subsequently died in circumstances related to abuse
or neglect, or in suspicious circumstances.
• The NSW Ombudsman were unable to establish the extent of
secondary risk of harm assessment for many of the 151 reports for 55 children that were referred from the
Helpline to Community Service Centres. Where secondary assessments were conducted,some assessments failed to identify risks to the child, or did not necessarily lead to effective protection for the child.
Neglect
Neglect was a significant issue raised in reports to DoCS about children who died. The deaths of 23 children were related to neglect. Thirteen of these children had been reported to DoCS. The NSW Ombudsman reviews raised concerns that reports of neglect may have required a greater level of assessment and response than was
provided.
Deaths of Aboriginal children and young people
Aboriginal children continue to be over-represented in child deaths in NSW: 48 of the 605 deaths in the reporting period were of Aboriginal
children. 62% of all deaths of Aboriginal children (30 children) were reviewable, compared with 23% of the deaths of children who were not Aboriginal. Seventeen of the 30 deaths were of infants under the age of 12 months. Fourteen of the children and young people died in circumstances related to abuse or neglect or in
suspicious circumstances. The NSW Ombudsman reviews have raised concerns that issues of neglect, parental misuse of drugs and alcohol, and domestic violence in the Aboriginal community are not being adequately addressed.
Interagency coordination and cooperation
The NSW Ombudsman's work indicates that the Interagency
Guidelines for Child Protection Intervention are
being under-utilised and that DoCS could better engage with other agencies in its child protection work. A key component of effective child protection intervention is strong advocacy by child protection caseworkers to
ensure implementation of case plans, particularly where other agencies also have responsibilities
within the case plan. The NSW Ombudsman saw little evidence of such advocacy.
The NSW Ombudsman also saw little evidence of DoCS making referrals to, or requests of, other agencies to
provide assistance in cases that were subsequently closed because the department did not have the
resources to respond directly. We note that DoCS, through the Child Protection Senior Officer’s Group, has commenced a process
of updating and review of the Interagency Guidelines
for Child Protection.
Source: "Reviewable Deaths Annual Report 2003-4: An
overview" Published December 2004 by NSW Ombudsman. It is available
to download as a PDF at http://www.nswombudsman.nsw.gov.au/publications/index.html
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