Report Exposes Systemic Failures in Child Protection System

Report Exposes Failures in Child Protection System

A long-awaited report by the Coroners Court of Victoria has revealed missed opportunities by child protection services that could have prevented the deaths of four infants between 2015 and 2017. The report, submitted to the inquest in 2023 by Principal Commissioner for Children and Young People Liana Buchanan, had been withheld from the public until Coroner John Cain ruled in favor of its release last month.

The report details several cases where child protection services failed to adequately assess and respond to risks faced by vulnerable children. In one instance, a two-year-old was killed and hidden in the roof cavity of her family home shortly after Child Protection closed its case. Ms. Buchanan reported that CP failed to properly assess the mother's new partner, despite knowing his history of family violence and multiple intervention orders against him.

Another case involved a mother who fatally lacerated her 13-month-old toddler's neck. CP closed the mother's case while she was hospitalized with postpartum psychosis, despite information suggesting risks to the child. Ms. Buchanan criticized the agency's referral of the mother to family support services, which she had previously refused to engage with.

The report also identified shortcomings in the services provided by the Victorian Aboriginal Child and Community Agency (VACCA) and the Uniting Church's community services network, Uniting Care (UC). In two cases, CP was unable to engage VACCA's Lakidjeka Aboriginal Child Specialist Advice and Support Service (ACSASS), resulting in the deaths of two infants. UC's approach to a case involving a 15-year-old girl was deemed "overly passive," with the organization failing to review or update her case plan after intake.

Ms. Buchanan's report calls for regular audits to ensure accountability and better outcomes for vulnerable children. She acknowledges the benefit of hindsight in her analysis and emphasizes the need to avoid criticizing individual actions.

Victorian Minister for Children Lizzie Blandthorn acknowledges the tragedy of these deaths and highlights the importance of changes made as a result of the report. The number of frontline child protection staff is expected to increase, and over 139,000 reports were made to CP about the wellbeing and safety of children in 2023-24.