The nature of the injuries the man inflicted on the infant boy are deeply distressing.

The man, who had also smoked meth during the night, repeatedly assaulted Jack. Medical examinations later showed it was highly likely Jack had been repeatedly shaken. There were injuries to his groin, neck, head and face, and he had either inhaled, ingested, or suffered environmental exposure to methylamphetamine.

A senior Child Protection practitioner involved in Jack’s case gave evidence to the inquest that they had been unaware of Jack’s mother’s new relationship with the man who would later be found guilty of the boy’s murder.

They added: “Based on my experience and professional judgement in [Jack’s] case, I did not believe that a Protection Application was warranted during the time of my involvement, noting that the matter was still in its investigation phase ... it was my view that there was no immediate or significant risk of harm to [Jack].”

Four children under the spotlight

For the past year, Victorian State Coroner John Cain has presided over an inquest examining the violent deaths of four children between 2015 and 2017, including that of Jack. The children’s deaths have already been the subject of criminal investigations. Cain’s task now is to investigate the extent to which failings in Victoria’s child protection regime contributed to them.

Three of the children are alleged or proven to have died at the hands of men linked to their families, while the fourth was killed by her severely mentally ill mother, who later pleaded guilty to infanticide.

Aside from their involvement with Child Protection, there are some clear similarities between the lives of the children, who were aged between 6 months and 15 years when they were killed.

Multiple reports had been made to Child Protection about the families of all four, and the 15-year-old girl had been removed from her mother’s care years earlier over concerns for her welfare.

Three were identified as being Aboriginal, while the fourth was from a recent migrant background. All had one or more of the following risk factors in their home lives: drug use in the home; a parent with severe mental illness; rough sleeping; their mother forming a new relationship; and their mother’s partner having a history of violence.

Over the course of the inquest Cain will consider whether, and how, Child Protection could have improved its practices in each of the children’s cases, and the processes under which external agencies Child Protection either contracts to, or works with, operated in each child’s case.

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He will also consider how Child Protection’s current policies and practices might prevent similar deaths occurring today; whether the training provided to Child Protection workers is consistent across the regions, and whether staffing and resourcing levels in different regions affect the supervision and oversight of practitioners.

In a crucial question for the sector, Cain will also be asked to consider the ideal workloads for Child Protection workers and whether there is adequate monitoring of workloads and training.

System under strain

Barrister Erin Gardiner, counsel for Child Protection, told the inquest it was increasingly difficult to find professionals to work in a sector characterised by long hours, high caseloads and challenging conditions.

In Victoria, Gardiner said, about 2000 Child Protection workers might grapple with 25,000 open cases at any one time.

“The organisation receives up to 130,000 reports each year concerning children potentially at risk of harm,” Gardiner said (according to the latest annual report, Child Protection Services received 118,096 notifications in 2021-22).

“Resourcing demands are such that [workers] must prioritise children most at risk. Families they work with usually have a constellation of issues going on. They range from social issues, drug and alcohol, trauma, which is sometimes intergenerational, mental illness, homelessness and unemployment; together often with low educational attainment, fractured family relationships and family violence.

“Child Protection workers are often met with resistance and sometimes hostility and aggression as they seek to go about their work.”

Gardiner also cautioned that Child Protection operates within the strict statutory framework of the Children, Youth and Families Act, which – as a core principle – holds that the state’s intervention should be limited to that necessary to secure the safety and welfare of children.

“With that exercise of judgement necessarily comes uncertainty and fallibility.”

Child homicides like those being investigated by Cain, Gardiner concluded, were “rare events that are often impossible to predict and to prevent”.

They are not as rare as we might like to think, however. In her latest annual report, Principal Commissioner for Children and Young People Liana Buchanan reported that 37 children known to Child Protection had died in the 2021-22 financial year. Of those, seven children died of “non-accidental trauma”. The cause of 11 other children’s deaths were either unclear or had not been resolved by the Coroner.

Problems with the ‘blitz’

In 2021, a whistleblower came forward to the Commission for Children and Young People, reporting concerns about a three-week “blitz” Child Protection had launched to reduce case numbers. It was called the ‘Child Protection: Managing high levels of work while ensuring the safety of children’ strategy.

The Commission, which scrutinises and oversees Child Protection, was unaware of the strategy and launched an investigation. It was damning. It found Child Protection launched the strategy to try to manage “staffing pressures, significant demand and the challenges brought about by the COVID-19 pandemic”, but the strategy “undermined the safety of children and young people, and exacerbated the risks of poor practice”.

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Cases had been reviewed and closed without Child Protection ensuring adequate supports were in place for the child and family – despite ongoing risk issues being evident.

“These findings mirror issues the Commission often identifies in child death and systemic inquiries,” the Commission found.

They also mirror issues being repeatedly raised in the current inquest.

In its latest annual report, the Department of Families, Fairness and Housing trumpeted the Andrews government’s Children, Youth and Families Amendment (Child Protection) Bill 2021 as a mechanism that would drive reform of the child protection sector. It was to reduce delays in permanently placing children in safe homes; elevate the rights of children; and promote Aboriginal self-determination within the system.

The bill followed a series of urgent recommendations to reform the sector, including by the Royal Commission into Institutional Responses to Child Sexual Abuse, the Victorian Ombudsman and the Commission for Children and Young People.

But politics got in the way. In June, The Age revealed the Andrews government had let its bill lapse in response to the Greens introducing an amendment to raise the age of criminal responsibility to 14 – despite the objections of the Greens and opposition. It instead passed a truncated version, designed specifically to address the needs of Aboriginal and Torres Strait Islander children.

Closing the file

Six weeks before 2½-year-old Amy* was discovered dead in her family home – having been bludgeoned and suffering extensive internal injuries and blood loss – a worker closed the file on her family.

Child Protection had received six notifications that children in the family home were at risk (including three before Amy was born), and Child Protection and workers from an external agency had visited the family home multiple times.

Internal files reveal workers were concerned with the level of chaos inside the home, including underwear and large volumes of “cat crap” on the floor, children jumping the fence to spend unsupervised time with an adult male neighbour, and Amy being noticeably dishevelled. During home visits Amy’s hair was matted, her clothes were grubby and snot was smeared across her face.

A senior caseworker from an external agency contracted by the Department of Health and Human Services told the inquest that, at the time, she had eight families on her books. Amy’s family was “at the lower scale of risk”.

“The main thing in the [child’s] case was around home environment, parenting skills and hygiene. Whereas for other families I had it is significant family violence, there’s failure to thrive – there’s inappropriate supervision, significant mental health, low-IQ families and the like.”

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In June 2015, Child Protection sought criminal record checks of the man Amy’s mum had begun seeing. The news was concerning: the new boyfriend had a string of criminal offences to his name, including assault occasioning bodily harm, assaults, stalking, family violence matters and intervention orders in three states.

Weeks later, a Child Protection worker wrote to an external agency worker: “Given the time lines [sic] on this case I will be looking to close the file ... I know [the boyfriend] is a concern, however given he hasn’t done anything to date, we cant [sic] hold the case open on the chance that he does start committing family violence. What do you think?”

Weeks later, Amy was dead. Her mum’s boyfriend was charged with her murder, but was found not guilty at trial.

The inquest continues.

*Names have been changed to comply with a suppression order covering the inquest.