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Legislative Assembly for the ACT: 2018 Week 08 Hansard (Thursday, 16 August 2018) . . Page.. 3094 ..


The committee report Changing the narrative for vulnerable children: strengthening ACT systems seeks to further our understanding of the risk factors that may increase a child’s vulnerability. Previous committee reports have found that the youngest children are the most vulnerable to early and often preventable deaths. While many of these deaths occur due to medical causes and extreme prematurity, the committee has taken the opportunity to consider some broader issues in younger children’s lives prior to their death. In preparing this report the committee examined the lives of 11 children under the age of three years who died prior to 2014.

All child deaths included in the review were subject to a closed coronial inquiry. In the majority of cases the coroner had reported the cause of death as “unascertained” or “undetermined”. These categories of death can be due to a range of causes where there is insufficient evidence to make an accurate determination.

Not all client files were available to the committee, and the findings of the review relate predominantly to information provided by child and youth protection services, ACT Health and Housing ACT. Coronial findings, police and autopsy reports were also considered.

The review considered 16 risk factors associated with increasing a child’s vulnerability. These factors are found at the individual, parent, community and socio-economic ecological level, and include domestic and family violence, drug and alcohol use, housing instability, mental health, physical health and low income.

The report highlights that understanding the effect of risk factors existing in the lives of children is complicated by the fact that these factors are often interrelated and intersect at multiple levels. It is also important to emphasise that the small cohort of children and the findings of this review are not representative of all child deaths in the ACT. Nonetheless the committee found that the complex characteristics of the lives of the 11 children echo extensive findings in national and international research.

All the children experienced one or more risk factors. Analysis of 16 principal risk factors evident prior to birth, and in the time leading to each child’s death, indicates that for six of the 11 children, life was chaotic, with 12 or more risk factors being present.

The provision of service supports to families was also analysed by the committee. This highlighted a number of systemic concerns which may have increased a child’s vulnerability. These concerns were frequently related to key services not fully recognising or responding to children’s needs.

The committee makes 19 recommendations related to improving system responses to reducing the vulnerability of children aged zero to three years. The recommendations relate to the policy and practices of government and non-government organisations.

The committee also recognises that significant changes have been made to the ACT service context since the deaths of the children in this review. These systemic changes have been brought about through the step up for our kids: out of home care strategy 2015-2020, the response to the Glanfield inquiry and the family safety


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