Reviewable deaths

Under Part 6 of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (CS CRAMA), a death of a child is a ‘reviewable death’ if that child: 

• was living in care or had been in detention at the time of death, and/or 

• had died as a result of abuse or neglect, or in circumstances suspicious of abuse or neglect. 

Section 36 of CS CRAMA requires the Ombudsman to monitor, review and maintain a register of reviewable deaths, and to: 

• formulate recommendations as to policies and practices to be implemented by government and service providers for the prevention or reduction of the reviewable deaths of children, and 

• undertake research or other projects for the purpose of formulating strategies to reduce or remove the risk factors associated with reviewable deaths that are preventable.  

The Ombudsman’s work on reviewable deaths focuses primarily on understanding service and agency interactions with the child who has died. We seek to identify agency practice and systems issues that may have contributed to reviewable deaths, or that may expose other children to risks in the future.  

As part of this work, we consider how agencies and service providers identified and responded to risks and vulnerabilities evident in the lives of the children and their families, as well as how relevant agencies communicated, consulted and collaborated with each other. We may also consider how relevant agencies responded to the deaths, such as the quality of subsequent internal reviews or investigations. 

Section 43(1) of CS CRAMA requires the Ombudsman to report to the NSW Parliament on a biennial basis about: 

• its work and activities in relation to reviewable deaths,  

• data collected and information relating to reviewable deaths, 

• any recommendations made, and 

• the implementation or otherwise of previous recommendations.  

Recommendations relating to reviewable deaths can be made in biennial reporting on reviewable deaths under section 43(1) of CS CRAMA, as well as in reports under section 43(3) of CS CRAMA.  

Explore our reports about reviewable deaths.