About

The CYP death review committee has the following functions:

• to keep a register of deaths of children and young people under part 19A.3;
• to identify patterns and trends in relation to the deaths of children and young people;
• to undertake research that aims to help prevent or reduce the likelihood of the death of children and young people;
• to identify areas requiring further research, by the committee or another entity, that arise from the identified patterns and trends in relation to the deaths of children and young people;
• to make recommendations about legislation, policies, practices and services for implementation by the Territory and non‑government bodies to help prevent or reduce the likelihood of the death of children and young people;
• to monitor the implementation of the committee’s recommendations;
• to report to the Minister under part 19A.4;
• any other function given to the committee under this chapter.

The CYP death review committee has no function in relation to reviewing the cause of death of a particular child or young person.

The Committee reports annually to the Minister for Children, Youth and Families. The Committee may also provide other reports to the Minister which may assist with reducing the likelihood of a child or young person’s death.

Confidentiality is important, and all reports prepared by the Committee must not identify a child or young person who has died.

Publications and further information about annual reports can be found on the Publications page.

The ACT is fortunate that a relatively small number of deaths of children and young people occur each year. However, this small number, together with the size of the ACT, both geographically and in population, means the Committee must pay particular attention to the way it reports its information. The Committee must ensure it complies with sections 727S(3) and 727T(2) of the Act, which do not allow for the disclosure of the identity of a child or young person who has died or allow the identity of a child or young person who has died to be worked out.

The Committee continues to prioritise the ongoing challenge of honouring the right to privacy of all children, young people and their family members while ensuring the community is able to benefit from examination of the circumstances that led to the death. The Committee adheres to the information-sharing provisions of Chapter 25 of the Act in that information obtained under the Act is only to be used for a function of the Committee. The Committee also adheres to Article 16 of the United Nations Convention on the Rights of the Child, which states: ‘Every child has the right to privacy. The law should protect the child’s private, family and home life.’

To meet these obligations the Committee undertakes a range of measures, including:

• the use of a secure register that can only be accessed by authorised staff
• password protection of documents when sharing any identifiable data during the obtaining of information
• assignment of an identification number to each child, young person, family member or relevant person
• provision to Committee members of de-identified information only about a child, young person, family member or relevant person.

The proposal for an ACT Children and Young People Death Review Team was first raised in 1999 by the Children’s Services Council. At that time, similar Child Death Review Teams had already been established in NSW and Victoria.

In 2004 the proposal for a Committee received further support from recommendations in the review undertaken by Ms Cheryl Vardon. This review focused on the safety of children in care and the management of Child Protection Services in the ACT. The review report ‘The Territory as Parent: Review of the Safety of Children in Care in the ACT and of ACT Child Protection Management’(known as the Vardon Report) was published in May 2004 and recommended that a child death review committee be established within a Commission for Children and Young People and that the Commissioner should chair the Committee. The report recommended that there should be a review of each child’s death for all children and young people who died when in the care of Family Services (now known as CPS) and/or when the Chief Executive had parental responsibility for the child and/or when the child was known to Family Services. These reviews would be carried out by an external reviewer and be provided to the Child Death Review Committee for consideration.

The government at that time agreed in principle with these recommendations. However, the Commission for Children and Young People had yet to be established and a decision as to the most appropriate location of a Child Death Review Committee was postponed.

In 2004 ACT Health established a model for a Child Death Review Team. This team relied on the powers of the ACT Chief Health Officer, under the Public Health Act 1997, to review child deaths from 1992 to 2003. The ACT Chief Health Officer chaired the Child Death Review Team whose membership was multidisciplinary and included those with a wide range of work expertise and experience. In June 2006, the Child Death Review Team published their work in a report entitled ‘Review of ACT Child Deaths 1992–2003’. The report examined general issues and trends and identified the need for appropriate legislation to guide the operation of an ongoing child death review mechanism. It did not report on individual child deaths.

In 2006 the ACT Government commissioned a study about intervention in the lives of children who had died or nearly died and who at some time in their lives were known to CPS (known as the Murray-Mackie Study). This independent study was undertaken by experts, Ms Gwenn Murray and Mr Craig Mackie, and its findings were reported to the then Department of Disability, Housing and Community Services (now known as the Community Services Directorate).

In September 2006 the then Minister for Disability and Community Services tabled the government’s response to the study, entitled ‘Recommendations from the Murray-Mackie Study into the Deaths and Near Deaths of Children Known to Care and Protection and the Government Response’, in the ACT Legislative Assembly. The recommendations of this study reiterated the recommendation made in the Vardon Report relating to a Child Death Review Committee. The then government agreed to implement this recommendation and to consider joint ACT Health and CPS clinical reviews of children who had died and who were known to both agencies prior to their deaths.

In January 2009 a memorandum of understanding was signed by ACT Health and the then Department of Disability, Housing and Community Services, including the OCYFS. This memorandum of understanding established a joint case review by the ACT Clinical Audit Committee of clients known to both ACT Health and CPS. When a review follows the death of a child known to CPS, the Clinical Audit Committee can make recommendations for systemic improvements involving individual agencies and in relation to collaborative practice between ACT Health Services and CPS. In a small number of cases, CPS has engaged an independent external reviewer to examine a death and produce a report.

In August 2010 Ms Meredith Hunter, MLA proposed amendments to the Act enabling the establishment of an ACT Children and Young People Death Review Committee. The proposed independent committee would complement and draw on existing review mechanisms, such as the ACT Office of the Coroner, the Clinical Audit Committee within ACT Health and any external or internal review process instigated by the then Department of Disability, Housing and Community Services. However, the role of the proposed committee would be fundamentally different and would mean, for the first time, a child death review mechanism specifically relating to the review of deaths of ACT children and young people would be enshrined in legislation.

The Bill and proposed government amendments were debated in the ACT Legislative Assembly and a final Bill was passed on 9 March 2011. These provisions became operational on 18 September 2011. The ACT Children and Young People Child Death Review Committee was established in accordance with the provisions contained in Chapter 19A of the Act. The first Committee meeting was held on 2 March 2012.

Future directions for the Committee are informed by its ongoing priority to become one of the leading bodies in the ACT in helping to prevent or reduce the likelihood of the death of children and young people. To achieve this, the Committee will:

• continue its reviews into the deaths of individual children and young people; each review contributes to the bigger picture and the identification of patterns and trends
• share what is learnt in an attempt to influence system changes, including in practice and service delivery
• continue to reach out to the ACT community with awareness campaigns and safety messages
• continue to maintain a register of all deaths of children and young people who die in the ACT and oversee cause of death coding
• provide relevant information to other jurisdictions as requested and when this sharing of information will not impact on the Committee’s responsibilities set out under the Children and Young People Act 2008.
• continue to be a member of the Australian and New Zealand Child death Review and Prevention Group (ANZCDR&PG) and attend any relevant meetings and conferences