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The Queensland Child Death Review model


The Child Death Register which is maintained by the Queensland Family and Child Commission (QFCC) records information about the deaths of all Queensland children regardless of cause. Data shows that mortality rates of children known to the child protection system are two times higher than the mortality rate of all Queensland children for external causes of death, such as drowning, other non-intentional injury, suicide, fatal assault and sudden unexpected infant deaths.  

A two-tiered review process – made up of Queensland Government agencies and the independent Child Death Review Board (CDRB) – helps to identify ways to improve the child protection system and promote the safety and wellbeing of children who come into contact with the child protection system. 

Internal agency reviews 

Chapter 7A of the Child Protection Act 1999 sets out the requirements for reviews following the death or serious physical injury of a child. Reviews must be undertaken by relevant agencies and the Director of Child Protection Litigation (DCPL). Relevant agencies include:

  • Child Safety
  • Education
  • Queensland Health 
  • Youth Justice
  • Queensland Police Service.   

A review is required when an agency has provided services to the child within the 12 months prior to their death or serious physical injury. When this occurs:

  • the head of the relevant agency must undertake a review of the relevant agency’s involvement with the child
  • if the DCPL has performed a litigation function in relation to the child, a review must be conducted by the Office of the Director of Child Protection Litigation’s (ODCPL) involvement in the matter concerning the child.

The purpose of reviews is to promote the safety and wellbeing of children who come into contact with the child protection system. Ways to facilitate ongoing learning, improve services, promote accountability and support collaboration and joint learning, must also be considered.

Reviews must be completed within six months of a triggering event. If the review relates to the death of a child, the review report is provided to the CDRB (the Board does not carry out systemic reviews of serious physical injuries).

The Operational guidelines for internal agency reviews provides guidance to agencies responsible for reviews. 

Child Death Review Board reviews

The CDRB conducts systemic reviews following the death of a child connected to the child protection system under Part 3A of the Family and Child Commission Act 2014.  

The purpose of the Board’s reviews is to identify opportunities to improve systems, legislation, policies and practices across the child protection system and preventative mechanisms to help protect children and prevent deaths that may be avoidable. 

The CDRB receives reports from each agency and the DCPL that conducted a review following the death of a child. It uses this information, research and data to make system-wide findings and recommendations. The CDRB has several functions and powers to assist it to do this.  

The CDRB Procedural Guidelines set out the procedures the Board uses to complete its reviews. Recommendations are published through its annual report.