Reviewable Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament
Reviewable Child Deaths in NSW 2022 and 2023 Biennial report to Parliament
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Reviewable Child Deaths in NSW 2022 and 2023 Biennial report to Parliament
PDF - 1MB
The Reviewable Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament 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.
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.
Caution: this report contains information about the deaths of children, including by suicide. Some people may find parts of this report confronting or distressing. If you need help or support, please contact
Aboriginal and Torres Strait Islander readers should be aware that this report includes information about deceased children.
We use the Mindframe guidelines[1] on responsible, accurate and safe suicide and self-harm reporting.
Data considerations
Reviewable child death statistics exhibit significant variability. Year-on-year changes in numbers should be interpreted with caution and be considered in the context of longer-term trend data where available.
This report concerns the reviewable deaths of children in NSW during 2022 and 2023. It also reports on our work and activities in relation to reviewable deaths since our last report in November 2023.
A death of a child is a ‘reviewable death’[2] if that child:
The NSW Ombudsman is required to review and report on these deaths over 2-year periods.
The appendices to this report set out definitions of terms used in the report (Appendix 1), more information about our role (Appendix 2), our review processes (Appendix 3), and other reviews and investigations that may occur in relation to a child’s death and how these relate to our reviewable death reviews (Appendix 4).
In 2022–2023: 38 reviewable deaths | |
Deaths as a result of abuse or neglect 22 | Deaths of children who were in care (of which 1 resulted from neglect) 17 |
In 2022 and 2023, the deaths of 38 children aged 0–17 years were reviewable deaths (22 in 2022 and 16 in 2023).[4]
Twenty-two children died as a result of abuse (11) or neglect (7), or in circumstances suspicious of abuse of neglect (4). One child who died of neglect was in care.
Deaths due to abuse occurred in the context of:
Deaths due to neglect occurred in a range of circumstances, including suicide (1), drowning (1), dog attack (1), Sudden Unexpected Death in Infancy (SUDI) (1) and transport-related incident (3).
Four other children died in circumstances suspected of being a result of abuse (2) or neglect (2).
Seventeen children died while living in care.
As noted above, 1 of these children died as a result of neglect. The other deaths were due to:
We are awaiting the final coronial outcome to confirm the circumstances of 1 death but the information to date indicates that they are not suspicious of abuse or neglect.
No child in detention died during 2022 and 2023.
Over the 10-year period (2014–2023), reviewable deaths each year have been a relatively small percentage of all child deaths (3.3%–4.8%).
While the total number of child deaths over the 10 years has decreased, the number of reviewable deaths has shown greater variability and no clear trend. Over the 10 years to 2023, the average number of reviewable deaths per year has been 21, with the lowest number of reviewable deaths in a year being 10 (2020) and the highest number being 25 (2015).
Table 1: Children whose deaths were reviewable in NSW in 2014–2023, number and percentage of all child deaths in 2-year intervals by reviewable status
2014–2015 | 2016–2017 | 2018–2019 | 2020–2021 | 2022–2023 | 2014–2023 | ||
|---|---|---|---|---|---|---|---|
All child deaths in NSW | 1,011 | 996 | 995 | 951 | 885 | 4,838 | |
Reviewable child deaths[5] | No | 49 | 43 | 47 | 31 | 38 | 208 |
%[6] | 4.8 | 4.3 | 4.7 | 3.3 | 4.3 | 4.3 | |
Abuse | No | 19[7] | 11 | 17 | 13[8] | 11 | 71 |
% | 1.9 | 1.1 | 1.7 | 1.4 | 1.2 | 1.5 | |
Neglect | No | 6 | 4 | 8 | 4 | 7[9] | 29 |
% | 0.6 | 0.4 | 0.8 | 0.4 | 0.8 | 0.6 | |
Suspicious | No | 3 | 4 | 3 | 4[10] | 4 | 18 |
% | 0.3 | 0.4 | 0.3 | 0.4 | 0.5 | 0.4 | |
In care | No | 23[11] | 24 | 19 | 13[12] | 17[13] | 96 |
% | 2.3 | 2.4 | 1.9 | 1.4 | 1.9 | 2.0 | |
A death due to abuse occurs when any act of violence by any person directly against a child or young person causes injury or harm leading to death. Abuse can refer to different types of maltreatment, including physical and sexual assault. Excluded from this definition are lawful acts of force that result in the death of a child or young person, for example, police discharge of a firearm to bring a dangerous individual under control.
In 2022 and 2023, the deaths of 11 children were identified as being a result of abuse (7 deaths in 2022 and 4 deaths in 2023). None of the children who died by abuse were living in care at the time of their death.
The 11 children died in 11 separate incidents:
Police investigations identified 18 males and 1 female responsible for, or allegedly responsible for, the deaths of the 11 children. In 3 cases, more than one person is implicated in the death. All 3 relate to instances of peer homicide.
Criminal charges against 8 individuals were finalised at the time of writing. Criminal proceedings are still underway for 10 persons of interest in relation to the deaths of 5 children. One case did not proceed to charges as the person of interest died by suicide at the time of the offence.
Further data and information about these abuse-related deaths is included in chapter 7 (Homicide) of the Child Deaths in 2022 and 2023 Biennial Report to Parliament.[14]
A death due to neglect occurs if a reasonable person would conclude that the actions or inactions of a carer (in not meeting a child’s basic needs such as supervision, medical care, nutrition, shelter) exposed the child to a high risk of death or serious injury, and the occurrence of that risk led to the death.
We categorise neglect-related deaths by the circumstances in which the child died:
In 2022 and 2023, 7 children died as a result of carer neglect (5 deaths in 2022 and 2 deaths in 2023). The 7 children were aged 9 months to 13 years old. Five of the 7 children were being cared for by their parents at the time of death.
These 7 children died by various causes in a range of circumstances of neglect by a carer including:
Of the 7 deaths, 4 were investigated by Police, and charges were laid in relation to the 3 transport deaths. Those criminal charges were as follows:
The investigation of the SUDI death was finalised without charges.
Carer impairment due to potential alcohol or drug use was identified in 3 of the 7 deaths, impacting the ability of a parent or carer to adequately supervise in 2 of those deaths, and the ability to provide appropriate care for the third child (a SUDI death).
A child’s death is considered suspicious (of abuse or neglect) where there is evidence that the death may have been due to abuse or neglect, but the evidence is insufficient for this to be reasonably determined.
A death is also classified as suspicious, even where it can reasonably be concluded that the death was due to abuse or neglect, if there are criminal proceedings on foot in relation to the death, and when those proceedings (including sentencing) are yet to be finalised.
In 2022 and 2023, 4 deaths occurred in circumstances that were suspicious of abuse or neglect (1 death in 2022 and 3 deaths in 2023).
These were the deaths of:
Carer use of alcohol and drugs has been identified as a factor in 2 of these deaths.
Section 4(1) of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (CS CRAMA) sets out the statutory and other arrangements for a child to be defined as ‘in care’, including various statutory care arrangements in the Children and Young Persons (Care and Protection) Act 1998.
In 2022 and 2023, 17 children died while living in care (9 in 2022 and 8 in 2023). The children were aged from 3 months to 17 years old.
As noted above, 1 of these children died as a result of neglect. The other deaths were due to natural causes (9), transport-related incidents (3), other unintentional external injury (1) and suicide (3). We are awaiting further information to confirm the circumstances of 1 death.
All the children (17) were in statutory care arrangements, including placements with authorised carers and relatives, and hospital and residential settings.
Seven of the children had lived with (and died because of) complex medical conditions, while 2 deaths were due to non-complex illness. Poor mental health against a background of trauma and abuse was a key factor in 4 deaths (3 suicides and 1 accidental overdose). Two of the 3 children who died by suicide had experienced a prior suicide attempt.
The death of a child who, at the time of their death, was an inmate of a children’s detention centre, a correctional centre or a lock-up (or was temporarily absent from such a place) is a reviewable death.[16]
There has been no reviewable death of a child in detention in NSW in the 10 years to 2023.
Our reviews are focused 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 death, such as the quality of subsequent internal reviews or investigations.
Two deaths during the 2022–2023 reporting period raised issues relating to post-death interagency collaboration and information sharing. These issues are discussed further in section 4.4, where these 2 deaths are included as case studies (alongside 8 others from earlier periods) that we have reviewed to inform our observations and recommendation to the NSW Government on these issues.
Given that some deaths in 2022–2023 continue to be the subject of police investigation, coronial inquiry and/or criminal proceedings, our reviews in many cases remain open.
In 2022 and 2023, 13 of the 17 children in care who died did not have a current Health Management Plan (HMP) (reviewed in the 12 months prior to their death) when they died.
HMPs are required under the out-of-home care (OOHC) Health Pathway Program (HPP), which is a joint initiative of NSW Health and the Department of Communities and Justice (DCJ) that aims to contribute to improved health outcomes for children and young people in OOHC. HMPs record the health needs and recommended health services for the child or young person in care, identified through 2 assessments (the Primary Health Assessment and the Comprehensive Health Assessment).
They are required to be developed within 90 days of entering care. They must be reviewed every 6 months for children under 5 years, or annually for children 5 years and older. Implementation of the pathway relies on DCJ/OOHC non-government organisation (NGO) caseworkers, NSW Health staff including coordinators, clinicians, GPs and carers.[17]
The HPP was formally evaluated in December 2022 and the evaluation identified that the unclear roles, responsibilities and accountabilities of NSW Health, DCJ and OOHC NGO caseworkers and primary care providers was a barrier to the effective implementation of the HPP.[18]
Examples of unclear roles and accountabilities were evident in some of our reviews. In the review of a 2022 death, the child had commenced on the HPP but there was no communication between the OOHC Health Pathway coordinator and the OOHC NGO regarding progress of the child’s health appointments and the need to develop a HMP, and referrals to specialists were not communicated to the OOHC Health Pathway coordinator. In another review of a 2023 death, the child’s plan was last updated 2 years prior to their death, and there were no records that the child’s HMP was provided to DCJ.
In their Serious Case Review (SCR) for a child who died by suicide in 2022 and was not on the HPP, DCJ acknowledged that enrolling the child in the program ‘would have provided an opportunity to consider not only [their] general health needs but what additional support [they] may have required for [their] mental health’.[19]
The evaluation made 16 recommendations for improvements,[20] which were accepted by DCJ and the Ministry of Health and which we have been monitoring.[21]
In July 2024, we recommended in our report Protecting children at risk: an assessment of whether the Department of Communities and Justice is meeting its core responsibilities that DCJ and the Ministry of Health review and report on progress with the implementation of the evaluation recommendations, how that implementation is impacting trends, and any proposed actions to be taken to address identified issues.[22]
DCJ and NSW Health accepted the recommendation and we are continuing to monitor its implementation, with further information expected in December 2025.
Our reviews of the deaths of children in care identified issues in some cases with the care and support they received. These issues – some of which have also been identified in DCJ’s SCRs – provide opportunity for learning and systemic improvement in the provision of services to children in OOHC. The issues included:
Since the last report in November 2023, we have provided 11 reviews concerning reviewable deaths to the Coroner to assist the coronial inquiries into those deaths (3 deaths occurred in 2022–2023).
In October 2025, we shared 2 reviews of deaths that occurred during 2022–2023 with the Clinical Excellence Commission (CEC) to inform the review of NSW Health’s Incident Management Policy.[24]
In this section we provide information about ongoing and systemic work that has flowed from our reviews of reviewable deaths.
The information in this section may not relate specifically to deaths that occurred in this biennial reporting period (that is, 2022–2023), but includes issues that we have taken action on in 2022–2023 that arose from reviews of deaths in earlier periods as well as, in some cases, deaths that have occurred since 2023.
In June 2023, we completed an investigation into a NSW Health local health district’s (LHD) response (in 2018) to a child who presented to hospital with suspicious injuries, and who later died as a result of abuse.[25]
At the time of issuing the investigation report, NSW Health’s Child Wellbeing and Child Protection Policies and Procedures contained a requirement for all health services to establish a range of child protection procedures, including:
We found that, while the LHD had identified child protection risks and made reports to the then Department of Family and Community Services (now the DCJ) at various points, the LHD’s conduct overall had been unreasonable.
We made 4 recommendations to the Ministry of Health and 1 to the LHD. The recommendations focused on policy and practice improvements and review of child protection resources.
We recommended that the Ministry of Health:
We recommended the LHD include a clear pathway for timely responses to requests relating to social (safety) admissions in its procedures that comply with ‘best endeavours’ requirements.[30] A safety admission refers to a person being admitted, or kept, in hospital for various reasons including their own safety, in circumstances when the admission is not required medically.
The Ministry provided updates in April 2024 and May 2025 advising that:
We continue to monitor the recommendations made to the Ministry.
The LHD provided an update in May 2025, and we met with them in September 2025. The LHD told us that it is developing new guidelines to implement our recommendation. It has also established internal and interagency meetings between the LHD and DCJ at the manager level, and the LHD, DCJ and NSW Police at the executive level to facilitate conversations on matters requiring close collaboration between the agencies. The LHD says it is currently piloting a new pathway for analysis and review of significant incidents from a child protection perspective that would not otherwise be reviewed under NSW Health’s Incident Management Policy.
We continue to monitor the recommendation made to the LHD.
Since 2017, if a child dies in in suspicious circumstances within 12 months of a presentation with a physical injury to a NSW Health facility, we may recommend that NSW Health, in conjunction with the Clinical Excellence Commission (CEC), conduct a comprehensive review of the interaction of that facility with the child and their family.
We have referred 3 deaths for review since 2017. All 3 referrals were accepted and reviews completed by either the CEC or SAER teams appointed by the CEC. The 3 reviews each considered key factors that may have contributed to the child’s death and identified opportunities for practice or systems improvements to enhance child safety systems, build the capability of clinical personnel to identify and manage children at risk, and improve outcomes for children and their families.
Two reviews were completed in August 2020 and December 2021, and their outcomes were reported in our previous biennial report.[32] The third review, referred to NSW Health in November 2023, was completed in August 2024 and is outlined below.
August 2024 review
The review considered NSW Health’s response to a vulnerable parent and their infant, where the infant had later died in circumstances of abuse. The parent attended multiple hospitals in the year prior to the infant’s death with concerns for the infant’s health, including a serious physical injury, as well as for their own mental health concerns.
The review conducted by NSW Health noted a general failure to recognise the parent’s vulnerabilities, and that presentations to the emergency department should have flagged escalating concerns for the infant’s welfare and the parent’s capacity to care for the infant. Record management and sharing, the utilisation of Pregnancy Family Conferencing,[33] reliance on DCJ to manage child protection concerns and failure to consider broader psycho-social circumstances were identified in the review.
The review was completed in consultation with DCJ representatives who provided information and input into the development of recommendations, including a joint recommendation to both agencies about statewide Pregnancy Family Conferencing guidance. Other recommendations related to general practitioner handover guidance, Mandatory Reporter Guide identification of cumulative risk, opportunities to extend an ‘injury screen’ state-wide as part of the development and roll-out of the Single Digital Patient Record, and “escalation processes within local services for identified risk of significant harm (ROSH)”.
The recommendations were to be implemented within 12 months of the review, and we are engaging with NSW Health about their progress implementing the recommendations.
Our review of the death of an infant in December 2019 in circumstances of abuse identified issues with Community Corrections’ case management of the father while he was under an intensive correction order and a community corrections order, as well as with NSW Police attendance at incidents involving the family. The infant’s father was subsequently convicted of manslaughter in relation to the death in August 2021.
Following review, we prepared reports to Community Corrections and NSW Police under s 43(3) of Community Services (Complaints, Reviews and Monitoring) Act 1993 (CS CRAMA).
We met with Community Corrections’ Acting Assistant Commissioner in June 2024, and Director, Quality Assurance, Delivery Performance and Culture in August 2024.
Our report to Community Corrections, issued in November 2024, collated our observations from the infant’s death, as well as 3 other deaths from 2019–2021 where Community Corrections was managing or had recently managed non-custodial sentences for individuals either responsible for, or named as a person of interest in, the deaths.
Our observations of Community Corrections’ case management of the infant’s father included:
Community Corrections provided advice about their practices and processes for case management of offenders, including considering the offender’s life and environment in addition to their offence/s and criminogenic risks in case management decisions. They advised about ongoing reform to improve offender compliance with case management requirements, promote critical thinking for their staff, and reform the Quality Assurance (reviews) function to improve the identification of opportunities for systemic improvement.
The report acknowledged the advice provided by Community Corrections in response to these observations.
Our observations of the NSW Police response to 2 domestic violence events involving the infant’s family in January 2019 included:
We also referred to an earlier coronial inquest into the death of ‘CS’, which identified similar and related issues.[34] The Coroner in that case recommended that NSW Police develop electronic prompts for officers on their obligations under the Crimes (Domestic and Personal Violence) Act 2007, review the DVSOPs and develop associated training including a case study featuring the circumstances of CS’s death.
Police acknowledged their failure to comply with the DVSOPs. They advised that the children did not need to be named in the ADVOs because they were protected by virtue of being captured under the definition of ‘domestic relationship’ under the Crimes (Domestic and Personal Violence) Act 2007.
In our final report to NSW Police, we advised that, in our view, the ADVOs were not compliant with the Crimes (Domestic and Personal Violence) Act 2007 because of the failure to name the children. We made 2 recommendations to NSW Police regarding the inclusion of guidance on the relevant sections of the Crimes (Domestic and Personal Violence) Act 2007 in the DVSOPs, and the provision of training on those sections to staff.
NSW Police accepted that the ADVOs were not compliant and accepted the recommendations. NSW Police has since advised that:
We are continuing to monitor NSW Police implementation of our recommendation.
Over the past 10 years, we have consistently called out a need for improved interagency collaboration across the spectrum of reviewable deaths, and specifically in relation to child protection and health services.
In 2017, we noted that ‘shared responsibility for protecting children has been the hallmark of the NSW child protection system since 2010’,[35] and how collaboration and information exchange across government and non-government agencies, and clarity regarding roles and responsibilities, were key challenges to address.[36] In relation to vulnerable children in care, we observed that when involved with multiple agencies, relevant information was not collated and analysed holistically at critical decision-making points, reducing the accuracy and effectiveness of that decision-making.[37]
In 2019, we identified the importance for children in care of good communication between out-of-home care (OOHC) service providers, NSW Health and medical practitioners; and collaboration, information sharing and comprehensive planning between DCJ and non-government agencies that case manage children for whom medical decisions are required.[38]
In 2021, we reported on ineffective interagency coordination, collaboration and information sharing in relation to deaths due to abuse and neglect.[39] We noted the need for coordinated service provision, clarification of roles and responsibilities, robust sharing of information, and the importance of intra-agency communication and interagency consultation.[40] We observed that more still needed to be done to improve case coordination, collaboration and information sharing for vulnerable families, and that we would continue to monitor agency practice in this area.[41]
In 2023, we noted that NSW Health reviews had identified a lack of interagency collaboration in relation to abuse-related deaths.[42] We reported on the importance of coordination, communication and collaboration between service providers to prevent familial homicide.[43]
Following the death of a child or young person aged under 18 years, some NSW Government agencies are required to complete a review of the death or of the agency’s involvement with a child and/or family in the period preceding the death.
These various review mechanisms, summarised in Appendix 4, provide an opportunity for agencies to reflect on their practice and service provision to identify contributing factors and critical issues and make recommendations that support continuous improvement.
Generally, agencies complete post-death reviews independently of each other and rarely share their completed individual reviews.
In our view, collaborating on reviews, or sharing learnings following a review, would allow agencies to leverage review processes already in place to identify and develop a comprehensive shared understanding of any issues relating to interagency interaction prior to the death, and agree on and implement joint solutions. This includes identifying systemic improvements to reduce the likelihood of future child deaths.
Our reviews of 10 reviewable deaths between 2018–2023 identified opportunities for vital information sharing and cross-agency learning about systems reform to improve child safety and wellbeing that were missed in the separate agency reviews conducted about these deaths.
The 10 cases included 8 children aged under 2 years who died in circumstances of abuse (or suspicious of abuse) and the deaths of 2 young people aged 16 and 17 years who were in care, 1 of whom died due to an unintentional overdose and 1 of whom died by suicide. The cases highlighted a number of issues relating to interagency collaboration and information sharing in post-death review practice and highlighted a need for a robust cross-agency post-death review process.
These included:
Single agency reviews may not consider critical information held by another agency that provides important context for the reviewing agency’s information.
For example, in 2 cases we considered, the reviews of DCJ and NSW Health held conflicting contextual information about significant interactions between those agencies. Without an opportunity to share their reviews, neither agency was able to consider the information held and assessed by the other, resolve any conflicting views and reflect on the other agency’s experiences of their practice.
In 1 case, the conflicting information held by the respective agencies led to different findings in each of their reviews and neither agency review making recommendations relating to cross-agency interaction. NSW Health did not make any recommendations, whereas DCJ made recommendations specific to their own internal systems.
In this same case, the agencies (as well as NSW Police) subsequently attempted to engage with each other to share the learnings from their own internal reviews. However, while the agencies shared the findings from their reviews, the meeting resulted in limited outcomes and many of the interagency issues raised either did not have a resulting recommendation or there was no clear commitment for action. This highlights the need for a robust process to assure that any interagency issues have been sufficiently addressed.
Effective agency interactions are critical to each agency’s decision-making, including assessing the risks to a child or family and providing appropriate supports. Understanding the perspective of other agencies in the context of their role and responsibilities is crucial to recognising the impact of decisions and provides an opportunity for improved collaboration and consultation.
In 5 cases, agencies’ decisions or actions impacted subsequent actions and/or decisions of other agencies. In 2 cases, it was apparent that a lack of understanding or incorrect assumptions made by 1 agency about the rationale for another’s agency’s decisions had influenced its actions (or decision not to act).
Currently a single agency review may identify where an agency’s actions were influenced by the decisions of another agency. However, without the ability to share their learnings with other relevant agencies, there is a missed opportunity for agencies to properly understand the potential impact of their actions and decisions and improve future interagency interactions. The individual agency review which preceded the NSW Health review discussed at section 4.2.1 identified that many NSW Health clinicians did not understand that if DCJ has closed a child protection case safety, welfare and wellbeing risks may continue to be present in a family. The review noted, “in practice this should trigger a heightened alert to risk for health services, as they then carry the responsibility of managing the risk without the support of DCJ”.
The ability to identify issues and to suggest and implement improvements is enhanced (or in some cases only possible) when agencies can come together and share learnings.
In 4 cases we reviewed, individual agency reviews by DCJ and NSW Health identified similar and related issues about interagency collaboration and communication. However, the lack of cross-agency consultation about these interagency issues resulted in missed opportunities for jointly developing recommendations to address them. The outcome was that recommendations in the individual agency reviews either:
Limited joint reviews and cross-agency discussions have occurred on an ad hoc basis, resulting in some positive outcomes. We identified circumstances where agencies conducted a joint review, or met to consider outcomes from their respective reviews, that resulted in recommendations to enhance and encourage information sharing and interagency management of child protection concerns.
In 1 case, referred to in section 4.3.1, DCJ and Community Corrections participated in a joint review process that recommended the establishment of a working group, with participants from both agencies, to review current practice and consider issues relating to information sharing. The outcome was positive and resulted in the implementation of changed processes to enhance and encourage information sharing between the agencies.
In a more recent case, DCJ and NSW Health met to consider the outcomes from their respective reviews and discuss critical issues about interagency management of child protection issues. The agencies acknowledged the importance of interagency collaboration in the post-death review process to support cross-agency learning and systems improvement and welcomed the opportunity for similar consultations in the future.
In a separate case discussed in section 4.2.1 of this report, DCJ participated in the August 2024 NSW Health review of an abuse-related death. DCJ provided NSW Health with information about current initiatives and reforms and NSW Health advised us that DCJ made significant input into the development of recommendations, resulting in recommendations that were both worthwhile and practical, including a joint recommendation to NSW Health and DCJ.
In the case of a 16-year-old who died by suicide and was in care, consultation and feedback from funded service providers to DCJ resulted in the identification of systemic concerns about the Intensive Therapeutic Care (ITC) program and recommendations for the review to be considered in any future work relating to reforms of the ITC model.
In 5 of the cases we reviewed, agencies indicated that they would be willing to share their reviews and learn from the experience of other agencies. However, in 2 cases, agencies advised us that barriers, such as pending criminal and coronial proceedings, prevented full disclosure and limited the opportunity for robust learning and improvement.
In another case, after DCJ and NSW Health had undertaken internal reviews, DCJ participated, to some extent, in the finalisation of the NSW Health internal review. This was productive, although we were again advised there were limitations to the information DCJ felt able to provide to inform the review.
Both DCJ and NSW Health advised that any interagency process would need to be supported by a legislative framework and facilitated by whole-of-government oversight. NSW Health also noted the issue of privilege ‘is one of the most significant impediments to cross-agency information sharing’.
Agencies have also cited resource constraints as a barrier to information sharing. In the case of a 17-year-old who died and was in care, the DCJ review recommended the development of a framework for a joint review function between DCJ and funded out-of-home care service providers. DCJ later decommissioned this recommendation for various reasons, including the significant resource investment required.
In the case of a 16-year-old who died by suicide and was in care, a joint review by DCJ and a non-government organisation was significantly delayed due to the need for ongoing consultation, although it has since been finalised. NSW Health also raised resourcing as a requirement for an effective interagency post-death review process during our consultation with them.
We consulted with a range of agencies in preparing this report and recommend, pursuant to s 36(1)(b) of CS CRAMA, the following:
The NSW Government should convene a cross-agency working group to develop a legislative framework for a cross-agency, post-child death review process. The legislative framework should provide for:
|
We are monitoring 2 recommendations made in relation to reviewable child deaths in previous biennial reporting. In the context of these 2 recommendations, we also note that we are currently undertaking an investigation under the Ombudsman Act 1974 into the Department of Communities and Justice’s (DCJ) response to children reported at risk of significant harm (ROSH), with findings expected to be tabled in early 2026.
Recommendation | When and why the recommendation was made | Agency response | Current status |
|---|---|---|---|
In the context of its triage policy and process review, the Department of Communities and Justice undertake a thematic analysis of its Serious Case Reviews (SCRs) relating to triage policies and practices over at least the previous 5 years, and:
| In our previous biennial report, we identified concerns regarding the rigour and transparency of triage assessments during the reporting period (2020–2021).[44] The concerns related to decisions about which children do or do not receive a child protection response (including an assessment and/or referral to another service), and how triage processes are assessing the needs and current supports for children reported at ROSH. | DCJ accepted the recommendation in principle in November 2023, noting that it had provided a number of SCRs to the Child Protection Policy team to assist with its current Prioritisation, Triage and Allocation Policy Review (Review). In December 2024 DCJ advised that it had conducted a thematic analysis of SCRs relating to triage policies and practices and that the analysis of those findings was also considered in the Review. DCJ confirmed in May 2025 that it would provide the final findings of the Review to the Ombudsman once ready. | Based on our review of DCJ’s Triage and Allocation Policy Review Discussion Paper and advice provided by DCJ, we are satisfied that SCRs relating to triage policies and practices have been analysed and the findings of this analysis are being considered in the Review. We await receipt of the report of the Review’s findings. |
The NSW Department of Communities and Justice require that a [Community Services Centre] which has referred a child to an agency in response to a ROSH report:
| There is a significant gap in knowledge about what happens to children and young people reported at ROSH who are referred to other services, rather than being allocated for a child protection assessment. In our biennial report for the 2018–2019 period, we recommended that DCJ advise of its actions to record the outcome of any referrals when a ROSH report is not prioritised for comprehensive assessment, including so as to prompt a review of its response to a ROSH report where the referral outcome was that the service provider was not able to actually provide the referred service. Advice was provided by DCJ in 2023, and that recommendation was closed. However, the advice did not indicate that DCJ does review its response to children where a service referral has been declined, and so we have made this further recommendation. | DCJ accepted the recommendation in principle in November 2023. In December 2024 it advised that the referrals process at triage had been considered as part of the Review. DCJ confirmed in May 2025 that, while all services to which children and families are referred are being considered in the Review, the Review has particularly focused on family preservation services due to DCJ’s greater capacity to track and influence these services, and their significance in addressing child protection risks. DCJ also advised that it is currently focusing on referrals made at triage. DCJ says it anticipates that additional guidance will be developed for caseworkers regarding when a matter should be held open to wait for a referral response, and when a declined referral will trigger further assessment of the information and a different response. It advised that it will consider strengthening guidance on responding to declined referrals during assessment and ongoing case planning in future.[45] | It is unclear from the advice provided by DCJ if its proposed new guidance, or other initiatives described as likely to flow from the Review, will require staff to take the actions described in our recommendation. We await receipt of the Review’s outcomes and the actions DCJ takes in response. |
Abuse – Any act of violence by any person directly against a child or young person that causes injury or harm leading to death. Abuse can refer to different types of maltreatment, including physical and sexual assault. Excluded from this definition are lawful acts of force that result in the death of a child or young person, for example, police discharge of a firearm to bring a dangerous individual under control.
Child – A person under the age of 18 years, as defined by section 34 of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (CS CRAMA). Unless otherwise stated, the terms ‘child’ and ‘children’ include both infants and young people, as defined below.
Child in care – A child ‘in care’ is defined by various provisions in s 4(1) of CS CRAMA.
The provisions in CS CRAMA are directly linked to various statutory care arrangements, such as those set out in the Children and Young Persons (Care and Protection) Act 1998.[46]
In 2022 and 2023, there were 3 main types of out-of-home care (OOHC):
The definition also includes children who are otherwise in the care of a service provider.
Child in detention – A child or young person who was an inmate in, or was temporarily absent from, a detention centre, a correctional centre or a lock-up.[48]
Child protection report - This is a term currently used by DCJ (which is not found in any legislation) to describe any report it receives that relates to a child’s safety, welfare and well-being.
Child Wellbeing Unit (CWU) – CWUs operate within NSW Health, the NSW Police Force and the Department of Education. CWUs assist staff in these agencies to meet their mandatory child protection reporting obligations.
Clinical Excellence Commission (CEC) – The CEC is the primary entity in NSW Health for system-wide leadership in clinical governance and safety assurance.
Community Services Centre (CSC) – DCJ locally-based community services offices. There are approximately 80 CSCs across NSW.
Computerised Operational Policing System (COPS) – COPS is the NSW Police Force’s core computer system for managing operation and administrative data.
Concerns report – This is a term currently used by DCJ (which is not found in any legislation) to describe any child protection report it receives that raises concerns about a child’s safety, welfare and well-being.
Concerns reports may include:
Co-sleeping – Where any person (including a child) is sleeping on the same surface as an infant, whether intended or not.
CS CRAMA – Community Services (Complaints, Reviews and Monitoring) Act 1993.
Department of Communities and Justice (DCJ) – The lead agency in the NSW Government Communities and Justice portfolio, which aims to create safe, just, inclusive and resilient communities through its services.[49] DCJ is the statutory child protection agency in NSW.
Domestic and family violence – Any behaviour in an intimate or family relationship, which is violent, threatening, coercive or controlling and causing a person to live in fear for their own or someone else’s safety. It is usually manifested as part of a pattern of ongoing controlling or coercive behaviour.[50]
Family Preservation Services – DCJ-funded NGO voluntary programs for family preservation. These services typically support families with ROSH reports, who have undergone DCJ safety and risk assessments and/or who have a child at imminent risk of entering OOHC.
As at 2025, the Family Preservation programs are:
As at 2025, DCJ funded 4,500 places per year for up to 12,500 children,[51] and was redesigning and recommissioning FPS services.
Child Protection HelpLine (HelpLine) – DCJ’s central contact point for receiving, screening and prioritising reports about children who may be at risk of significant harm.
Infant – A child less than 1 year (12 months) of age.
Mandatory report (section 27 report) – A report made by a mandatory reporter who has reasonable grounds to suspect that a child is at ROSH (Children and Young Persons (Care and Protection) Act 1998, s 27).
Mandatory reporter - A person prescribed in s 27(1) of the Children and Young Persons (Care and Protection) Act 1998, who has a duty to report if they have reasonable grounds to suspect that a child is at ROSH.
This includes any person who, in the course of their professional work or other paid employment, delivers health care, welfare, education, children’s services, residential services, or law enforcement, wholly or partly, to children.
Ministry of Health – The Ministry supports the Secretary, the NSW Minister for Health and Minister for Regional Health, the Minister for Mental Health and the Minister for Medical Research to perform their executive government and statutory functions. The Ministry is also the system manager for the NSW public health system and consists of ministry branches, centres and offices.
Neglect – A death is classified as due to neglect if a reasonable person would conclude that the actions or inactions of a carer (in not meeting a child’s basic needs – such as supervision, medical care, nutrition, shelter) exposed the child to a high risk of death or serious injury, and the occurrence of that risk led to the death.
Non-ROSH report – This is a term currently used by DCJ to describe concerns reports that have been screened in by the HelpLine as not being a ROSH report.
NSW Police Force (NSWPF) – NSW’s law enforcement agency whose role is to protect the community and property.
Peer – For the purposes of this report, a ‘peer’ is a young person who is the same or similar age and/or social grouping.
Register of Child Deaths (NSW) – Section 34D(1)(a) of CS CRAMA requires the CDRT to maintain a register of child deaths occurring in New South Wales since 1 January 1996.
ROSH – The definition of ‘at ROSH’ is in section 23 of the Children and Young Persons (Care and Protection) Act 1998.
A child or young person is at ROSH if ‘current concerns exist for the safety, welfare or well-being of the child or young person because of the presence, to a significant extent, of any one or more of’ the circumstances set out in that section. Circumstances include where the child or young person has been, or is at risk of being, physically or sexually abused or ill-treated.
ROSH report – This is a term currently used by DCJ to describe concerns reports that have been screened in by the HelpLine as a ROSH report. A concerns reports is screened in by the HelpLine as a ROSH report if the HelpLine considers that the report suggests the child may be at ROSH.
Screened in – This is a term currently used by DCJ to describe a process, after a concerns report is received by the HelpLine, of the HelpLine classifying that report as either a ROSH report or a non-ROSH report.
Serious Case Review (SCR) – A SCR is a review process conducted by the SCR Unit within the Department of Communities and Justice (DCJ) when a child known to DCJ (who was reported to DCJ as suspected of being at risk of significant harm (ROSH) within three years of their death, or who was in OOHC at the time of their death) dies. The reviews consider the local and organisational systems that impacted practice with the families of the child who died, and identify areas for practice improvement as well as positive practice to support organisational learning and inform system improvement.
Serious Adverse Event Review (SAER) – A SAER is a review of a patient safety event that results in or could have resulted in death, serious harm or a sentinel event, and is not an expected outcome of the patient’s illness. The review is conducted by a team of NSW Health staff with relevant knowledge who were not directly involved in the incident. The team prepares a report with findings and any recommendations aimed at preventing or mitigating any factors that caused or contributed to the incident, or unrelated system improvements, for the Ministry of Health to consider and implement.
Statutory response duty – Section 30 of the Children and Young Persons (Care and Protection) Act 1998 requires that, on receipt of a voluntary (section 27) report or a mandatory (section 24) report:
(Note that s 30 does not apply to prenatal reports.)
Sudden Unexpected Death in Infancy (SUDI) – The death of an infant that is sudden and unexpected, where the cause was not immediately apparent at the time of death. SUDI is not a cause of death, but is a descriptive term applied at the point an infant is found deceased.
Suicide – includes deaths where:
• a Coroner found that the cause and manner of death was self-harm with fatal intent
• Police identified the death as suicide and the case remains open with the Coroner, or
• the Coroner dispensed with an inquest and has not made a finding about the manner of death, but Police identified the death as suicide and records examined provide evidence of self-harm with fatal intent.
Suspected ROSH – This is a term currently used by DCJ to describe a situation where a concerns report has been screened in as a ROSH report, but DCJ has not completed such investigations and assessment as it considers necessary to determine whether or not the child or young person is at ROSH.
Suspicious – A child’s death is classified as suspicious (of abuse or neglect) where there is evidence that the death may have been due to abuse or neglect, but the evidence is insufficient for this to be reasonably determined.
Triage – Process of prioritising and deciding actions for ROSH reports against resources at a local CSC.
Voluntary (section 24) report – A report made by any person who has reasonable grounds to suspect that a child or young person is at ROSH (Children and Young Persons (Care and Protection) Act 1998, s 24), and that is not a mandatory report.
World Health Organization (WHO) – A specialised agency of the United Nations responsible for international public health.[52]
Year – unless otherwise stated, means calendar year.
Young person – a child aged 15–17 years (inclusive).
Under part 6 of CS CRAMA, a death of a child is a ‘reviewable death’ if that child:
Section 36 of CS CRAMA requires the Ombudsman to monitor, review and maintain a register of reviewable deaths, and to:
Section 43 of CS CRAMA requires the Ombudsman to report to the NSW Parliament on a biennial basis about:
Our reviews involve seeking and examining relevant records and information relating to the children who died, and in particular their interactions with government agencies and government-funded community service providers.
We maintain the NSW Register of Child Deaths, which contains the register of reviewable deaths. Information for this report has been drawn from the Register of Child Deaths.
Under s 38 of CS CRAMA, a range of agencies and practitioners are required to provide our Office with ‘full and unrestricted access’ to records that it reasonably requires for the purpose of exercising its reviewable death function. We either specifically request information from agencies, or access information through direct access to relevant databases (such as ChildStory[54] and Justice Link[55]).
Our reviews and this report have been informed by a range of sources including:
The key focus of our reviews is 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.
We may also consider how relevant agencies responded to the death, such as the quality of subsequent critical incident investigations.
As well as considering individual agencies’ interactions with the children and their families, we also assess how relevant agencies communicated, consulted and collaborated with each other. This systems perspective can highlight issues that may not be evident or able to be addressed in an agency-specific review. In this regard, our reviewable death function can facilitate deeper understanding of interagency communication, process and practice issues to identify learnings and systemic improvements.
Much of our work in relation to reviewable deaths is necessarily out of the public view, in part to protect the privacy of the deceased children and their families. We work with agencies to address practice and systems issues to ensure protection of children and improved support to vulnerable families. This work involves a range of activities, including:
The outcomes of this work are included as appropriate in this report.
NSW has several related mechanisms for reviewing the deaths of children, which interact with our reviewable death function in various ways.
In addition to having responsibility for reviewable deaths, the Ombudsman is the Convenor of the NSW Child Death Review Team (CDRT).
The CDRT reviews the deaths of all children in NSW, for the purpose of preventing and reducing the likelihood of deaths of children in NSW. The CDRT includes experts in healthcare, child development, child protection and research, as well as representatives of key government agencies. Ombudsman staff undertake work to assist the CDRT, including maintaining and analysing information contained in the Register of Child Deaths, preparing statutory reports, monitoring recommendations and performing secretariat functions. Our office has had this responsibility since 2011.
The CDRT reports biennially on data collected and analysed in relation to child deaths that occurred in a 2-year period. The CDRT’s Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament[56] is referenced in this report where relevant and provides further information about causes and classifications of deaths over the 2-year period and 15-year trends (2009–2023).
The CDRT launched its own website in early November 2025, which contains CDRT information, publications and reports.[57] Some CDRT information and reports are also available on the NSW Ombudsman website.[58]
Under s 172A of the Children and Young Persons (Care and Protection) Act 1998, DCJ must review and report on the deaths of children known to them. This includes the death of a child if the child and/or a sibling were the subject of a report of suspected ROSH in the 3 years prior to the child’s death, or where the child was in OOHC at the time of their death.[59]
These reviews are completed by the SCR Unit within DCJ and:
… consider how local and organisational systems impact on practice with the families of children who died. The reviews create learning opportunities for practitioners who work with families by not only identifying areas for practice improvement but also promoting positive practice. This in turn leads to broader system improvements. The findings from reviews are used to support organisational learning and system improvement.[60]
When a child dies in a non-government OOHC setting, DCJ may work with the non-government OOHC provider as part of their review process, with some reviews being undertaken jointly.
DCJ’s annual child death reports are tabled in Parliament and are available on DCJ’s website.[61]
Reviewable deaths are also coronial deaths under the Coroners Act 2009. The role of the NSW Coroner is to investigate certain kinds of deaths in order to determine the identity of the deceased, and the date, place, circumstances and cause and of death. The Coroner may hold an inquest and can make recommendations to governments and other agencies with a view to improving public health and safety and preventing future deaths.[62] Inquest decisions can be found at the Coroners Court website.[63]
We regularly provide information (such as copies of reviews) on request to the Coroner to assist with their inquiries relating to inquests, as well as under our own initiative on occasion where we consider the information may assist.
The NSW Coroner convenes the NSW Domestic Violence Death Review Team (DVDRT), which includes representatives of relevant government and non-government agencies. The Team reviews deaths that occurred in the context of domestic violence, including the deaths of children.
We provide information upon request to the DVDRT. Information about the DVDRT, including its reports, can be found at the Coroner’s Court website.[64]
All NSW Health services are required to routinely review and report on the deaths of infants that occur within the first 28 days of life,[65] as well as all deaths that occur in hospitals.[66]
Additionally, in accordance with s 21H of the Health Administration Act 1982, when serious patient harm occurs, NSW Health undertakes a SAER to find out what happened, why it happened and how to prevent a similar incident happening again.[67]
These various reviews aim to identify system weaknesses that may have caused or contributed to the incident, learn from experiences, improve care and reduce the likelihood of future deaths.
In our Report of Reviewable Deaths 2014–15, we recommended that if a child dies in suspicious circumstance within 12 months of being presented to a NSW public health facility with a physical injury, and the NSW Ombudsman considers an internal review is warranted, NSW Health, in conjunction with the CEC, should establish a process for a comprehensive review of the interaction of that facility with the child and their family.
This recommendation was accepted by NSW Health and to date 3 deaths have been reviewed (discussed further at section 4.2).
Other government agencies may also complete an internal review following the death of a child. For example, when a serious incident occurs, Corrective Services NSW may complete a Critical Incident Review of their prior involvement with the family of a child who has died; or the NSW Department of Education may conduct their own follow-up in response to the death of a child that was enrolled in a NSW Government school at the time of their death by suicide.
In this report, underlying cause of death is reported using the World Health Organization (WHO) International Statistical Classification of Diseases and Related Health Problems ICD-10-AM.[68] This classification document has more than 12,000 unique codes in more than 2,000 categories. The highest-level classification is the chapter level (22 chapters).
Underlying cause of death is defined by the WHO as the ‘disease or injury that initiated the train of events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury’. Unless otherwise indicated, in this report the cause of death relates to underlying cause. The underlying cause of death is recognised as the single most essential element to understanding causes of death.[69]
From 2013 onwards, and in line with recommendations by the Australian Institute of Health and Welfare, data that identifies Aboriginal and Torres Strait Islander children are obtained from all available sources for each case reviewed and recorded in the Register of Child Deaths:
‘Mindframe guidelines: Communicating about suicide’ Mindframe (Web Page, 2025) <https://mindframe.org.au/suicide/communicating-about-suicide/mindframe-guidelines>. ↑
Section 35 of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (CS CRAMA). ↑
We assess whether a child’s death was due to abuse or neglect, or suspicious of abuse or neglect using the definitions set out in this report. ↑
This number was correct at the time of writing. The number of children whose deaths are classified as reviewable can change over time as more information becomes available. ↑
There were no deaths of children in detention between 2014 and 2023. ↑
Of all child deaths in that reporting period. ↑
Two of the children who died due to abuse were also in care. ↑
Two of the children who died due to abuse were also in care. ↑
One of the children who died due to neglect was also in care. ↑
One of the children who died in suspicious circumstances was also in care. ↑
Two of the children who died due to abuse were also in care. ↑
Two of the children who died due to abuse were also in care; one of the children who died in suspicious circumstances was also in care. ↑
One of the children who died due to neglect was also in care. ↑
Child Deaths Review Team, Child Deaths in 2022 and 2023 Biennial Report to Parliament (Biennial Report, 5 November 2025) <https://cmsassets.ombo.nsw.gov.au/assets/CDRT/NSW-Child-Death-Review-Team-Biennial-Report-2022-2023.pdf>. ↑
As at September 2025. ↑
This does not include deaths in custody, or as a result of police operations as defined by s 23 of the Coroners Act 2009. ↑
Implementation of the HPP pathway relies on DCJ/OOHC NGO caseworkers, NSW Health staff including coordinators, clinicians, GPs and carers. DCJ caseworkers are responsible for completing the referral to NSW Health to place a child on the HPP within 14 days of their entry into care. It is then the responsibility of the OOHC Health Coordinator to gather relevant information about the child’s health, organise the Primary Health Assessment to take place within 30 days of the child entering care, organise any follow-up assessments (Comprehensive Health Assessments) and develop a HMP within 90 days. For children case managed by DCJ, it is the caseworker’s responsibility to ensure the HMP is included in the child’s records, ensure it is incorporated into the child’s case plan, ensure the HMP is implemented, and that any identified health issues are followed up. The caseworker is also responsible for ensuring the HMP is periodically reviewed by the OOHC Health Coordinator or a health practitioner. ↑
NSW Ministry of Health, Final Evaluation Report Executive Summary: OOHC Health Pathway Program enhancement funding (Report, 2 December 2022) 5 <https://www.health.nsw.gov.au/kidsfamilies/MCFhealth/Documents/exec-summary-2022-OOHC-HPP-eval.pdf>. ↑
NSW Department of Communities and Justice Office of the Senior Practitioner, Internal Child Death Review BS (March 2023) 52 ↑
NSW Ministry of Health, Final Evaluation Report Executive Summary: OOHC Health Pathway Program enhancement funding (Report, 2 December 2022) <https://www.health.nsw.gov.au/kidsfamilies/MCFhealth/Documents/exec-summary-2022-OOHC-HPP-eval.pdf>. ↑
NSW Ombudsman, Biennial report of the NSW Ombudsman under section 43 of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (Report, 27 November 2023) 182 <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Biennial-report-of-the-deaths-of-children-in-NSW-2020-and-2021.pdf>. ↑
NSW Ombudsman, Protecting children at risk: an assessment of whether the Department of Communities and Justice is meeting its core responsibilities (Report, 5 July 2024) 61 <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Protecting-children-at-risk-report-2024.pdf>. ↑
The SCR stated that practitioner resources and support for carers is being developed as part of the placement stability project within the High Cost Emergency Strategy Unit. ↑
NSW Health, Incident Management Policy (Policy Directive, 14 December 2020) <https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2020_047.pdf>. ↑
The Ombudsman Act 1974 investigation followed our review of the death under pt 6 of Community Services (Complaints, Reviews and Monitoring) Act 1993 (CS CRAMA). A summary of this investigation is included in NSW Ombudsman, Formal investigations summary report 2022–23 (Report, 30 October 2023) <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Formal-Investigations-Summary-report-2022-23.pdf>. ↑
NSW Health, Child Wellbring and Child Protection Policies and Procedures for NSW Health (Policy Directive, 15 April 2023) 11 <https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2013_007.pdf>. ↑
Ibid 13. ↑
Ibid 13–14. ↑
NSW Health, Child Wellbeing and Child Protection Policies and Procedures for NSW Health (Policy Directive, 15 April 2013) 13 <https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2013_007.pdf>. ↑
Legislation and policy requires NSW Health to use its ‘best endeavours’ to comply with requests by DCJ for a child to be admitted, or to remain in hospital, where there are clear concerns about the child’s safety, welfare and wellbeing. ↑
‘Child protection’, NSW Government and The Sydney Chidlren’s Hospitals Network (Web Page, 2025) <https://www.schn.health.nsw.gov.au/child-protection>. ↑
These reviews were reported on in our biennial report of reviewable deaths in 2020 and 2021: NSW Ombudsman, Biennial report of the deaths of children in New South Wales: 2020 and 2021 (Biennial Report, 27 November 2023) 178–9 <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Biennial-report-of-the-deaths-of-children-in-NSW-2020-and-2021.pdf>. ↑
The NSW Government’s Pregnancy Family Conferencing program supports expectant parents and their families where there are concerns about the safety and wellbeing of an unborn child. It provides early intervention to help families plan for a successful start in their parenting journey and keep mothers and their children together. ↑
Coroners Court of New South Wales, ‘Inquest into the death of CS’ (Coroner’s Inquest, 15 July 2022) <https://coroners.nsw.gov.au/documents/findings/2022/Inquest_into_the_death_of_CS_-_Final_Findings_-_Delivered_15_July_2022.pdf>. ↑
NSW Ombudsman Report of Reviewable Deaths 2014 and 2015 (Biennial Report, June 2017) 63 <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Report-of-reviewable-deaths-2014-and-2105_Child-deaths_Vol1_June17.pdf>. ↑
Ibid 9, 18, 63. ↑
Ibid 64. ↑
NSW Ombudsman, Biennial report of the deaths of children in New South Wales: 2016 and 2017 (Biennial Report, 25 June 2019) 49 <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Biennial-report-of-the-deaths-of-Children-in-NSW_2016-17.pdf>. ↑
NSW Ombudsman, Biennial report of the deaths of children in New South Wales: 2018 and 2019 (Biennial Report, 25 June 2019) 92 <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Biennial-report-of-the-deaths-of-children-in-NSW_2018-and-2019.pdf>. ↑
Ibid 98. ↑
Ibid 99. ↑
NSW Ombudsman, Biennial report of the deaths of children in New South Wales: 2020 and 2021 (Biennial Report, 27 November 2023) 121 <https://cmsassets.ombo.nsw.gov.au/assets/Reports/Biennial-report-of-the-deaths-of-children-in-NSW-2020-and-2021.pdf>. ↑
Ibid 122. ↑
Ibid 185–7. ↑
We note that DCJ’s paper Finalising the Family Preservation foundational elements describes peak bodies and service providers supporting DCJ’s proposed requirement that cases be held open for up to 3 months while a Family Preservation Service provider engages with the family: Department of Communities and Justice, Finalising the Family Preservation foundational elements – Working together to design a more effective and more responsive system for children, young people, and families (Paper, December 2024) 20 <https://dcj.nsw.gov.au/documents/service-providers/deliver-services-to-children-and-families/family-preservation/finalising-the-family-preservation-foundational-elements-paper.pdf>. ↑
Section 135 of the Children and Young Persons (Care and Protection) Act 1998. ↑
The definition of voluntary OOHC was repealed on 1 September 2022. ↑
Section 35(1)(e) of CS CRAMA. ↑
‘About DCJ’, NSW Government, Communities and Justice (Web Page, 21 March 2025) <https://www.dcj.nsw.gov.au/about-us/who-we-are-and-what-we-do/about-dcj.html>. ↑
What is domestic and family violence?, Department of Communities and Justice (Web Page) <https://dcj.nsw.gov.au/legal-and-justice/safer-pathway/what-is-domestic-and-family-violence.html> ↑
DCJ, Redesigning Family Preservation in NSW – Discussion Paper (2024), p.10; DCJ, System review into out-of-home care (2024), 2.3.1. ↑
This report covers work and activities undertaken since the last reviewable report was tabled (27 November 2023). ↑
ChildStory is DCJ’s information management system for children and young people in OOHC and child protection. ↑
JusticeLink is the information management system for the NSW Government justice system including the NSW State Coroner. ↑
Child Deaths Review Team, Child Deaths in 2022 and 2023 Biennial Report to Parliament (Biennial Report, 5 November 2025) <https://cmsassets.ombo.nsw.gov.au/assets/CDRT/NSW-Child-Death-Review-Team-Biennial-Report-2022-2023.pdf>. ↑
See <https://cdrt.ombo.nsw.gov.au>. ↑
See <https://www.ombo.nsw.gov.au>. ↑
Department of Communities and Justice, 2023, Child Deaths 2023 Annual Report: Learning to improve services (Annual Report, November 2024) <https://dcj.nsw.gov.au/documents/children-and-families/child-deaths-annual-reports/child-deaths-2023-annual-report.pdf>. ↑
Ibid 7. ↑
See <https://dcj.nsw.gov.au/children-and-families/child-deaths-annual-reports.html>. ↑
‘Role of the Coroner’, Coroners Court of New South Wales (Web Page, 16 September 2025) <https://coroners.nsw.gov.au/how-the-coroners-court-work/role-of-the-coroner.html>. ↑
See <https://coroners.nsw.gov.au/coronial-findings-search.html>. ↑
See <https://coroners.nsw.gov.au/resources/domestic-violence-death-review.html#Reports%3Cbr%3E2>. ↑
NSW Health, Investigation, Review and Reporting of Perinatal Deaths (Policy Directive, 26 September 2022) <https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2022_046.pdf>. ↑
See <https://www.cec.health.nsw.gov.au/improve-quality/system-safety-culture/person-centred-care/end-of-life/death-screening-and-database-project> ↑
NSW Health, Clinical Excellence Commission, Serious adverse event review: Information for staff affected by a serious incident (Guidance, November 2020) <https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0019/622027/SAER-information-for-staff.pdf>. ↑
Independent Hospital Pricing Authority, ICD-10-AM International Statistical Classification of Deiseases and Related Health Problems, Tenth Revision, Austrlaian Modification, Twelth Edition, 1 July 2022. ↑
National Centre for Health Information Research and Training, Review and Recommendations for the Annual Reporting of Child Deaths in NSW (NSW Ombudsman, Report, 2011, unpublished). ↑
We acknowledge the traditional custodians of the land on which we work and pay our respects to all Elders past and present, and to the children of today who are the Elders of the future.
Artist: Jasmine Sarin, a proud Kamilaroi and Jerrinja woman.