Lost to suicide, known to child protection

News 14 November 2019

Their voices are lost to us, but we must do whatever we can to somehow hear them, because doing so will save lives.

They are the 35 children and young people who committed suicide within a year of their last involvement with Victoria’s child protection system. Their stories, and the story of the system that failed them, are captured in Lost, not forgotten, a report the Commission for Children and Young People this week tabled in the Parliament of Victoria.

They are not the only children and young people who died having been known to child protection, but their cases illustrate themes that ripple out through a deeply flawed and pressured system responsible for the care of the most vulnerable, the most at risk.

Together, 229 child protection reports were made about these children and young people – an average of seven reports each – with 90 per cent closed at intake or investigation, the earliest stages in the child protection process.

Through all of these reports, many of which began at a very young age, these children and young people were never engaged with effective services that potentially could have saved them. They were shuffled between child protection and family services and back again, time and again before their cases were finally closed for the last time, in some cases just weeks before the child or young person’s death.

It sounds almost glib to call this the refer-and-close roundabout, but that was the pattern we repeatedly saw, and it is still happening for many children and young people in the system. We can’t know with precision just whose risk will become fatal, but surely we can put in place the resources, policies and practices that will give us the best chance of reaching them in time.

Through their short lives, these children and young people accumulated terrible harm. Nearly all were victims of family violence, 89 per cent suffered from some form of neglect, and 51 per cent were sexually abused. They were typically disengaged from education (83 per cent), and a large majority had contact with a mental health service (89 per cent).

As they grew older, so did the complexity of the challenges facing them, and so too the challenge of providing interventions that would give them a chance. Too often they grew to be seen as children and young people who were ‘difficult’ rather than as desperately needing help. The system failed them, and then they died.

How can things change? We know from a report of the Victorian Auditor-General, and from recent reports in the media, that the pressures on child protection workers are relentless, the system profoundly under-resourced. We know, too, that early intervention services that can prevent risks proliferating and spiralling into deadly complexity too often simply aren’t there.

We know that in the scramble of overwhelming demand, families that become disengaged are allowed to fall into the fatal gap between statutory child protection and voluntary family services.

It should not be possible for a case to be closed in the presence of suicidal risk without the best service response we can provide. It should not be possible that a child or young person’s death by their own hand follows their abandonment by the system intended to care for them.

Our recommendations to the Victorian Government are framed to address these realities, to ensure that, along with sustainable resources, child protection workers have the guidance they need to work with children and young people at risk of taking their own lives, that there is in place a suicide prevention strategy for all children and young people involved with the child protection system.

We must also consider this. The children and young people whose suicides we have considered in Lost, not forgotten are those who die within the narrow window of a year since their last child protection involvement. We do not know how many die beyond that year, nor how many die after they turn 18. That means we must accept that our consideration of the toll in this report is conservative, our recommendations more urgent for the unknown scale of the tragedy.

It is the legal nature of the child death inquiries on which this report is based that they will never be public. To many, these children and young people will remain faceless. But I know them, as do the Commission staff who work to learn from their deaths. They know the circumstances in which they died, how they sought the connection, friendships and love that every child and young person deserves.

Beyond that, and most importantly of all, these children and young people are known by the people who loved them and will never see them again.

These children were not the responsibility of just one government. They were failed under multiple governments. This cannot be characterised as only a political failing – we must acknowledge it as a collective failing by a community that does not demand better for our children.

Nothing now can change their stories, but we know there are specific actions the Victorian Government can take to stem the tide of future loss. There is no answer to this call for action but to act.

Liana Buchanan is Victoria’s Commissioner for Children and Young People.

This opinion piece was first published in the print edition of the Herald Sun on Thursday 14 November 2019.


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