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 e