Child death inquiries

We hold inquiries into services provided to a child or young person who dies within a year of involvement with Child Protection.

About our inquiries

We are required to hold inquiries about services provided to children who died and were known to Child Protection in the 12 months prior to their death (Commission for Children and Young People Act 2012 s34).

We conduct child death inquiries to promote improvement in policies and practices for the safety and wellbeing of vulnerable children and young people. They allow us to examine a child's experience and identify ways in which the system can be improved for the benefit of children and young people in the future.

Child death inquiries do not seek to determine the causes of death; that is the job of the Coroner and Victoria Police.

What we look into

Child death inquiries take a systemic view of services that were, or weren’t, provided throughout the child’s life.

We engage service providers, professionals, parents and carers to consider the effectiveness of services. From there we draw out learnings to influence future policies and practices.

How we conduct child death inquiries 

In conducting inquiries we:

  1. formally establish an inquiry after the Department of Families, Fairness and Housing notifies us about a child's death
  2. request access to information, documents and records from all relevant service providers and professionals 
  3. invite individuals from relevant services to participate in interviews (if appropriate or necessary)
  4. contact the child’s parents and carers about the inquiry and invite them to share their experiences of services
  5. review information and draft a report that analyses services the child received throughout their life - this report may include recommendations to improve service responses
  6. give services, parents and carers an opportunity to respond to any adverse comment or opinion in the draft report
  7. finalise the report and share it with the Minister for Children, the Secretary of the Department and any other minister if relevant.


Child death inquiry reports are not public documents. We provide a copy to the Minister for Child Protection and Family Services, and the Secretary of the Department. We may also share the report with another minister if we consider it covers a matter in their remit.

We report on statistics and emerging trends in our annual reports