NSW Child Death Review Team and ‘Reviewable’ deaths of children in NSW

Who we are

NSW has two independent statutory functions relating to the review of the deaths of children (0 – 17 years) in NSW. Both are undertaken within the Office of the NSW Ombudsman:

  • The NSW Child Death Review Team (CDRT) is established under Part 5A of the Community Services (Complaints, Reviews and Monitoring) Act 1993. The purpose of the Team is to prevent and reduce the deaths of children in NSW. The NSW Ombudsman is Convenor of the Team, and Ombudsman staff provide administration and support to the Team, including research and reviews.
  • Separately, and under Part 6 of the Community Services (Complaints, Reviews and Monitoring) Act 1993, the Ombudsman is responsible for reviewing the deaths of children and young people who die as a result of abuse or neglect, or in suspicious circumstances, and children who die in care or in detention (‘reviewable’ deaths).

What we do

The focus of both functions is to help prevent the deaths of children. The legislation describes how we should do this:

  • We maintain a register of child deaths and reviewable deaths in NSW. The register holds a range of information about each child who has died, including demographic, health, and cause and circumstances of death.
  • From the information held in the register, we identify trends and patterns in relation to child deaths. We report trends and other issues in biennial reports to the NSW Parliament, and release the reports publicly.
  • We undertake research - either alone or with others -  that aims to help prevent or reduce the likelihood of child deaths. We report our research to the NSW Parliament and release reports publicly.
  • We make recommendations as to legislation, policies, practices and services that can be implemented by government and non-government agencies and the community to prevent or reduce the likelihood of child deaths. We also monitor and report on agency progress with implementation of our recommendations.

Who notifies deaths to the Ombudsman?

The NSW Registry of Births, Deaths and Marriages provides us with initial information about the deaths  of children. We then seek records from relevant agencies in order to fulfil our functions. Most agencies – both public and relevant private providers – are required by our legislation to provide us with ‘full and unrestricted’ access to records that we reasonably require to do our work.

Our work in preventing the deaths of children

The main purpose of our reviews is identify any opportunities to prevent children in the same circumstances from harm in the future. This is at two levels:

  • At an individual level, the circumstances of death may highlight a particular risk.
  • At a population level, we may be able to identify trends that point to the need for action to prevent deaths in certain demographic groups or from certain causes.

In most cases, our review takes place after all other inquiries and investigations are completed. We use all of this information to understand what led to a child’s death, and to identify any opportunities for systems improvement.

The outcomes of our work, and our recommendations for change, are presented directly to the NSW Parliament:

  • For both the Child Death Review Team and the Ombudsman’s reviewable child death work, we prepare child death review reports for the Parliament every two years. The reports include information about trends and patterns in child deaths, risk factors associated with the deaths of children and mitigating or protective factors, and recommendations to government and non-government agencies, and the community.
  • For both the Child Death Review Team and the Ombudsman’s reviewable child death work, we prepare research reports for the Parliament on a regular basis. The research focuses on particular issues, taking account of the trends we have seen over a period of time. In most cases, we commission experts in a relevant field to conduct our research, in consultation with CDRT members and staff. Examples of our research include:
    • Child deaths from vaccine preventable infectious diseases, NSW 2005–2014
    • Reporting of fatal neglect in NSW
    • A scan of childhood injury and disease prevention infrastructure in NSW
    • Causes of death of children with a child protection history 2002–2011

If you would like more information about our work, and to access our reports.

Contact us for more information

Our business hours are: Monday to Friday, 9am–5pm (Inquiries section closes at 4pm)
If you wish to visit us, we prefer you make an appointment. Please call us first to ensure your complaint is within our jurisdiction and our staff are available to see you.

Level 24, 580 George Street
Sydney NSW 2000

Email info@ombo.nsw.gov.au

General inquiries 02 9286 1000
Facsimile 02 9283 2911
Toll free (outside Sydney metro) 1800 451 524
National Relay Service 133 677

Telephone Interpreter Service (TIS) 131 450
We can arrange an interpreter through TIS or you can contact TIS yourself before speaking to us.

© State of New South Wales, July 2017
This publication is released under a Creative Commons license CC BY 4.0.

Publication metadata

ISBN 978-1-925569-41-4
Category Fact sheets
Publication Date 17 August 2017