14.1 Child death case reviews
Purpose
This procedure outlines the process for undertaking child death case reviews, following the death of a child known to the department.
Authority
- Child Protection Act 1999, section 246A
Requirements for a review
The death of any child, known to the department within the three years prior to their death, will be subject to a child death case review (Child Protection Act 1999, section 246A).
A child death case review is conducted where:
- the department was aware of alleged harm or risk of harm to the child;
- the department took action in relation to the child under the Child Protection Act 1999; or
- the chief executive reasonably suspected the child would need protection once they were born, although they were not born at the time the suspicion arose.
With respect to unborn children, child death case reviews will not be undertaken where a child is stillborn or where the pregnancy is miscarried.
For the purpose of child death case reviews, a 'case' is defined as any ongoing involvement or any action or intervention that the department has taken in relation to the child, including:
- intakes and child concern reports;
- notifications (including notifications with a protective advice response), initial assessments and investigation and assessments;
- a child subject to child protection orders, assessment orders, child protection follow up, intensive family support or intervention with parental agreement; and
- any other action under the Child Protection Act 1999, even if not recorded at the time of the child's death.
Focus of child death case reviews
The focus of the review is on the appropriateness of departmental involvement with a child and their family, as opposed to the cause of death of the child.
Child death case reviews are conducted to:
- ensure accountability and transparency in departmental decision making, practice and procedures;
- identify required improvements in departmental systems, policies and practice;
- identify trends regarding the deaths of children known to the department and inform research with respect to child protection practice;
- facilitate ongoing learning and development and improvement in the provision of services by the department; and
- provide information for quality improvement strategies.
Every effort is made to ensure case reviews are conducted in a culturally appropriate way.
In developing the terms of reference for a child death case review, consideration will be given to case specific issues and the potential for organisational learning to be generated through an examination of the issues.
Type of review - external or document based
All child death case reviews are undertaken by an independent reviewer who is contracted by the Director-General to undertake the review in collaboration with a departmental reviewer.
The review involves the reading of all case documentation, preparing a chronology of departmental involvement with the child, detailing and analysing departmental responses to the issues of the case and identifying any policy, procedural or practice gaps. This involves interviewing current departmental staff and ex-departmental officers and staff from other entities, as appropriate.
The independent reviewer completes a report which is provided to the Director-General and the Case Review Unit. If it is determined that the report is deficient or does not address the terms of reference in a way that is acceptable to the department, a supplementary report is completed by the Case Review Unit.
Freedom of indemnity or defamation
The Child Protection Act 1999, section 246E and 246F, provides freedom from indemnity or defamation for anyone participating in a child death case review, who acting honestly, gives information to the chief executive and is acting in good faith.
Provision of completed child death case reviews
A completed child death case review (comprising the independent review report and any other supplementary report) is submitted to:
- the internal Child Death Review Committee; and
- the external Child Death Case Review Committee.
- Last updated
- 30 June 2007
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