35 children deemed not at significant risk by protective services before their deaths

Dozens of children have died over a six-year period despite the state’s protection services receiving an average of almost eight reports per child about the dangers they were facing at home, a new inquiry has found.

The Commission for Children and Young People’s Left Behind report, which was tabled in parliament on Thursday morning, found all of the 35 children who died between 2019 and 2025 had been the subject of between two and 28 reports. There were a total of 267 reports between them over their lives, 231 of which were closed at intake or at the investigation stage.

The commission’s first report focused on referrals to voluntary services, where a statutory response is not necessary – and how early intervention and prevention can relieve pressure on an overwhelmed system.

Last year, 75 per cent of children and young people reported to child protection were subject to a previous report – 52 per cent within the previous year, and 63 per cent within the previous two years, the report found.

Of those who did not meet the threshold for a child-protection intervention, and were referred to family services, 58 per cent could not be contacted or declined engagement.

“We call this the ‘refer-and-close roundabout’ because the cases of these children and young people are often closed without effective – or indeed any – intervention,” Commissioner for Children Tracy Beaton said.

“That child is actually still left in the same circumstances, and what will happen is that we’ll see a repeat referral when another incident occurs,” she said.

“So what we’re really concerned about is that that child is still left holding risk and trauma.”

None of the 35 deaths could be attributed to anything that has happened within the system, with suicide and accidental death caused through incidents such as house fires or drowning being the most common causes.

However, the report found that all had presented with multiple risk factors that often escalated over time, with the most common risk factors including family violence, substance misuse and mental health issues.

Beaton said there was “overwhelming pressure” on a “dedicated and hard-working child and family system”.

“That undermines consistent risk assessment, leads to ineffective referrals to pressured services, and to low engagement amid long waiting lists, even when families do choose to engage,” Beaton told The Age.

She said earlier intervention, a shared understanding of risk and referral outcomes and ensuring that children and young people get access to services – especially family violence services – are all essential.

Beaton also said the experiences of young people “are often lost” in the process of getting families to engage with services – the families who need to provide consent for family services to speak with the children.

“Children and young people will tell us that their voices aren’t heard,” she said.

“The people who might be responsible for harm might actually be saying ‘no, we don’t want to see anyone, we don’t need to see anyone yet’,” she said.

Policy work was also required to ensure children were able to engage in services in their own right, Beaton said, noting early intervention and prevention were important, but weren’t always accessible.

The CCYP, which relinquished the reportable conduct scheme to the Social Services Regulator in February, now focuses purely on advocacy, oversight and inquiries.

Between 2022 and 2025, reports to child protection regarding children at risk increased by 23 per cent.

In 2025, there were 151,000 reports to child protection in Victoria, with a workforce of about 2500 – about 60 reports per worker.

Australian Centre for Child Protection director Leah Bromfield said there are families known to child protection for a long period of time, but that isn’t always translating to receiving help.

“It’s the referral roundabout that kids and families don’t get off. Where a referral made doesn’t equate to a service received,” she said.

Bromfield said repeat investigations for one child had become normalised, due to overwhelmed family-support and child-protection systems with insufficient services to meet demand.

“When you aren’t bad enough, you don’t get accepted; that’s particularly problematic for chronic negligence or chronic poverty or disadvantage,” she said.

If services tried to engage with parents in multiple ways, Bromfield said, it could result in better outcomes, with parents actually understanding the seriousness and the need to act.

On Wednesday, the Victorian Auditor General’s Office tabled a damning Out-of-Home Care Services independent assurance report in parliament.

The report found the Department of Families, Fairness and Housing was not fully meeting the needs of the 9353 children in out-of-home care in Victoria, where young people were subject to a statutory child-protection intervention, and a children’s court magistrate determined a child should not be with their parents.

It also found the department preferenced kinship care, where children are placed with a relative or someone they already know, and that the department’s understanding of children’s needs and system demand was limited.

Victorian kinship carers currently receive the lowest fortnightly care allowance in the country.

Kinship Carers Victoria Anne McLeish said the pressure on families – with cost of living and busyness – had increased considerably, meaning fewer people were able to be foster carers.

“I’ve never known a generation of grandparents to be as busy as this,” McLeish said.

She said the department was placing children with somebody other than a member of the family or a close friend – in some cases that was a school teacher or childcare worker – because “they’re desperate to keep the children in a family home environment rather than in an institution”.

“If you consider that, then we should be grateful that the department is doing that,” McLeish said.

“The problem is that they shouldn’t just leave them there without going through the rest of the exercises about finding family.”

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