This section sets out the work of the Office in relation to its child death review function. Information on this work has been set out as follows:
In November 2001, prompted by the coronial inquest into the death of a 15 year old Aboriginal girl at the Swan Valley Nyoongar Community in 1999, the (then) State Government announced a special inquiryinto the response by government agencies to complaints of family violence and child abuse in Aboriginal communities.
The resultant 2002 report, Putting the Picture Together: Inquiry into Response by Government Agencies to Complaints of Family Violence and Child Abuse in Aboriginal Communities, recommended that a Child Death Review Team be formed to review the deaths of children in Western Australia (Recommendation 146). Responding to the report the (then) Government established the Child Death Review Committee (CDRC), with its first meeting held in January 2003. The function of the CDRC was to review the operation of relevant policies, procedures and organisational systems of the (then) Department for Community Development in circumstances where a child had contact with the Department.
In August 2006, the (then) Government announced a functional review of the (then) Department for Community Development. Ms Prudence Ford was appointed the independent reviewer and presented the report, Review of the Department for Community Development: Review Report (the Ford Report) to the (then) Premier in January 2007. In considering the need for an independent, inter-agency child death review model, the Ford Report recommended that:
Subsequently, the Parliamentary Commissioner Act 1971 was amended to enable the Ombudsman to undertake child death reviews, and on 30 June 2009, the child death review function in the Office commenced operation.
The child death review function enables the Ombudsman to review investigable deaths. Investigable deaths are defined in the Ombudsman’s legislation, the Parliamentary Commissioner Act 1971 (see Section 19A(3)),and occur when a child dies in any of the following circumstances:
In particular, the Ombudsman reviews the circumstances in which and why child deaths occur, identifies patterns and trends arising from child deaths and seeks to improve public administration to prevent or reduce child deaths.
In addition to reviewing investigable deaths, the Ombudsman can review other notified deaths. The Ombudsman also undertakes major own motion investigations arising from child death reviews.
In reviewing child deaths the Ombudsman has wide powers of investigation, including powers to obtain information relevant to the death of a child and powers to recommend improvements to public administration about ways to prevent or reduce child deaths across all agencies within the Ombudsman’s jurisdiction. The Ombudsman also has powers to monitor the steps that have been taken, are proposed to be taken or have not been taken to give effect to the recommendations.
By reviewing child deaths, the Ombudsman is able to identify, record and report on a range of information and analysis, including:
Communities receives information from the Coroner on reportable deaths of children and notifies the Ombudsman of these deaths. The notification provides the Ombudsman with a copy of the information provided to Communities by the Coroner about the circumstances of the child’s death together with a summary outlining the past involvement of Communities with the child and the child’s family.
The Ombudsman assesses all child death notifications received to determine if the death is, or is not, an investigable death. If the death is an investigable death, it must be reviewed. If the death is a non-investigable death, it can be reviewed. The extent of a review depends on a number of factors, including the circumstances surrounding the child’s death and the level of involvement of Communities or other public authorities in the child’s life. Confidentiality of the child, family members and other persons involved with the case is strictly observed.
The child death review process is intended to identify key learnings that will positively contribute to ways to prevent or reduce child deaths. The review does not set out to establish the cause of the child’s death; this is properly the role of the Coroner.
At the commencement of the child death review jurisdiction on 30 June 2009, 73 cases were transferred to the Ombudsman from the CDRC. These cases related to child deaths prior to 30 June 2009 that were reviewable by the CDRC and covered a range of years from 2005 to 2009. Almost all (67 or 92%) of the transferred cases were finalised in 2009-10 and six cases were carried over. Three of these transferred cases were finalised during 2010-11 and the remaining three were finalised in 2011-12.
During 2018-19, there were 30 child deaths that were investigable and subject to review from a total of 78 child death notifications received.
Total Number of Notifications Received 2009-10 to 2018-19 |
|
The Ombudsman commenced the child death review function on 30 June 2009. Prior to that, child death reviews were undertaken by the CDRC with the first full year of operation of the CDRC in 2003-04.
The following table provides the number of deaths that were determined to be investigable by the Ombudsman or reviewable by the CDRC compared to all child deaths in Western Australia for the 16 years from 2003-04 to 2018-19. It is important to note that an investigable death is one which meets the legislative criteria and does not necessarily mean that the death was preventable, or that there has been any failure of the responsibilities of Communities.
Comparisons are also provided with the number of child deaths reported to the Coroner and deaths where the child or a relative of the child was known to Communities. It should be noted that children or their relatives may be known to Communities for a range of reasons.
Year |
A |
B |
C |
D |
Total WA child deaths |
Child deaths reported |
Child deaths where the child or a relative of the child was known to Communities |
Reviewable/ investigable child deaths |
|
2003-04 |
177 |
92 |
42 |
19 |
2004-05 |
212 |
105 |
52 |
19 |
2005-06 |
210 |
96 |
55 |
14 |
2006-07 |
165 |
84 |
37 |
17 |
2007-08 |
187 |
102 |
58 |
30 |
2008-09 |
167 |
84 |
48 |
25 |
2009-10 |
201 |
93 |
52 |
24 |
2010-11 |
203 |
118 |
60 |
31 |
2011-12 |
150 |
76 |
49 |
41 |
2012-13 |
193 |
121 |
62 |
37 |
2013-14 |
156 |
75 |
40 |
24 |
2014-15 |
170 |
93 |
48 |
33 |
2015-16 |
178 |
92 |
61 |
41 |
2016-17 |
181 |
91 |
60 |
50 |
2017-18 |
138 |
81 |
37 |
23 |
2018-19 |
165 |
81 |
37 |
30 |
Notes
Information is obtained on a range of characteristics of the children who have died including gender, Aboriginal status, age groups and residence in the metropolitan or regional areas. A comparison between investigable and non-investigable deaths can give insight into factors that may be able to be affected by Communities in order to prevent or reduce deaths.
The following charts show:
As shown in the following charts, considering all 10 years, male children are over‑represented compared to the population for both investigable and non‑investigable deaths.
Number of Notifications by Gender |
Title Text (Note - you have to use hard returns at the end of each paragraph otherwise it turns the text to paragraph font which you do not want). |
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