Children under state care dying at almost twice the rate of all Queensland children: board report

Children known to Queensland’s child protection system are almost twice as likely to die as others in the state.

That bleak statistic is revealed in the opening line from the Chair of Queensland’s Child Death Review Board (CDRB) in her message from the Board’s inaugural 2020-21 annual report tabled in state parliament on Thursday (17 Feb).

The independent CDRB commenced operation on 1 July 2020 and was established by the Queensland Government to examine the deaths of 55 children known to the child protection system.

In her opening ‘Message from the Chair’, Cheryl Vardon says: “Children known to the child protection system die at almost twice the rate of all Queensland children.”

“Some are placed in out-of-home care if their families are found to be unable to care for them, while others have had less serious contact.

“Some attend school, some receive health services, and some engage in behaviours that bring them to the attention of the police and the youth justice system.


“In most cases, there are many eyes on these children before they die, although some very young children remain at risk of becoming invisible.”

Ms Vardon said there were entrenched systemic issues that currently impacted on the timeliness and quality of responses to children and families.

“Concerningly, the overrepresentation of Aboriginal and Torres Strait Islander children – both within the child protection system and among children who have died – persists,’’ she said.

“We must do better.

“Our recommendations call for specific actions, but in implementing these, agencies must work with Aboriginal and Torres Strait Islander peoples and organisations to make sure actions are culturally responsive.

“I am also committed to ensuring Aboriginal and Torres Strait Islander peoples have meaningful involvement in review processes and in leading decisions about issues affecting their children.”


Queensland Attorney-General Shannon Fentiman yesterday thanked the CDRB for its report and the work it was doing to protect children.

“The death of a child in any circumstances is an absolute tragedy and it’s crucial that when a child known to the child protection system dies, we learn from these tragedies to prevent future deaths,” Ms Fentiman said. 

“The (CDRB) conducts comprehensive and systemic reviews of child deaths that extend beyond reviewing key government agency services to an individual child.”

Ms Fentiman said the Board had been tasked to consider matters relating to the provision of services to, and other interactions with, children and their families by government and non-government entities.

She said the ‘Child Death Review Board Annual Report 2020-21’ examined the deaths of 55 children connected to the child protection system and included in its report 10 recommendations to government agencies to address systemic issues, and a call for agencies to take specific actions regarding policies, procedures and practices.

Queensland Minister for Children and Youth Justice Leanne Linard said the Board’s recommendations were in response to its findings across three focus areas.


“The Board specifically examined and made recommendations surrounding engagement with targeted secondary services, the accuracy and quality of child protection assessments, as well as the accessibility and availability of suicide prevention and support after a suicide,” Ms Linard said.

“A number of important initiatives that seek to implement the Board’s recommendations are already underway across government, and additional programs, policies and practices will undergo further development in the coming months to help protect vulnerable children and young people from harm.”

Ms Fentiman said that in addition to the Board’s annual report, the Government had received the Queensland Family and Child Commission’s (QFCC) ‘Annual Report: Deaths of children and young people, Queensland, 2020-21’.

“The QFCC maintains a register of information relating to all child deaths in Queensland,” Ms Fentiman said.

“The annual report analyses this information and reports on trends and patterns over time to inform research, policies, programs and public education campaigns to reduce deaths and to help keep children safe.

“The Commission’s analysis of child deaths in Queensland provides a valuable resource and will inform both government and non-government death prevention activities and measures.”


Ms Vardon was the QFCC’s principal commissioner and author of the Commission’s 2020-21 annual report.

In January (2022), QFCC’s chief executive Luke Twyford replaced Ms Vardon as principal commissioner.

Read the ‘Child Death Review Board Annual Report 2020-21‘.

Read the Queensland Family and Child Commission’s 2020-21 annual report.

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