NSW Ombudsman tables the Reviewable Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament

Today we tabled the Reviewable Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament. 

This report concerns the reviewable deaths of children in NSW during 2022 and 2023, and our work and activities in relation to reviewable deaths since its last such report in November 2023. 

Reviewable deaths are those that occur when a child was living in care or detention at the time of death, and/or where the death is due to abuse, neglect, or occurs in circumstances suspicious of abuse or neglect. 

In the 2-year period 2022–2023 there were 38 reviewable deaths of children in NSW. Of these, 22 children died due to, or in circumstances suspicious of, abuse or neglect. 17 children died while living in out of home care (including 1 who died due to neglect). 

NSW Ombudsman, Paul Miller, said: “Reviewing the deaths of children in these situations helps us understand system interactions and identify issues that may have contributed to the deaths. We use these findings to recommend necessary changes to help prevent those issues from occurring in future. We may also consider how relevant agencies responded to the deaths, such as the quality of subsequent critical incident investigations.” 

This report identifies some shortfalls in the care and support that had been provided to children who died in out of home care during 2022 and 2023, including failures to develop and maintain current health management plans for those children.  

It also reports on the Ombudsman’s examination of 10 child deaths between 2018−2023 that had involved post-death reviews by relevant agencies, such as the Department of Communities and Justice and NSW Health. The report identified gaps in information sharing between agencies when each conducted its own post-death review, and consequently missed opportunities for cross-agency learning about possible system improvements. 

The Ombudsman concluded that deeper collaboration during post-death review processes would allow for potentially conflicting information held by agencies to be identified and resolved, and for them to better understand critical points of interaction and decision-making during the child’s life and in the period leading to their death. It would also reduce barriers to shared learning, and facilitate the development and implementation of effective interagency recommendations.  

“Following consultation with key stakeholders, we have recommended that the NSW Government develop and introduce a legislative framework for a cross-agency post-child death review process,” Mr Miller said. 

The report also details the Ombudsman’s other prevention work, including monitoring the implementation of previous recommendations it has made relating to reviewable deaths. 

"On behalf of the NSW Ombudsman, I want to extend my sympathy to the families and friends who have lost an infant, child, or young person. It is our responsibility that, in reviewing these deaths, we learn from them and use that knowledge to make a difference.” 

Read the full report.