1. Insights from the Australasian Seminar on Child Death Inquiries and Reviews Promoting the learning from child death inquiries and reviews: Where to from here ? Held in Melbourne 2-3 June 2008

2. Today’s topics: The contested nature of inquires Recognising the value of inquires Key considerations Learning from each other

3. The overwhelming response by welfare states to child deaths and other systems failures has been to seek bureaucratic solutions by introducing more law, procedures and guidelines the more risk and uncertainty has been exposed the greater the attempts to close up the gaps through administrative change Ferguson 2004:10 Why do child death inquires? They just create bureaucratic solutions and demand compliance

4. Finally, since the findings of any next inquiry could reasonably be predicted before it has taken place, we would like to propose that no further inquiries are commissioned before all the training and resource deficiencies identified over the last thirty years have been remedied. Reder & Duncan 2004:112 Why do child death inquires? They haven’t improved practice up to this point

5. Child death inquires have often made matters worse as they typically focus only on the last link of in the chain of events which could have avoided a tragic outcome. It is like building a system of road safety only on an analysis of factors impairing driver decision making immediately prior to a fatal accident when paying attention to factors such as car and road design is also vitally important Scott 2006 :10 Why do child death inquiries? Their focus is too narrow

6. The cumulative results of thirty years of child abuse inquiries have created the traditional solutions, psychological pressure to avoid mistakes, increasingly detailed procedures and guidelines, strengthened managerial control to ensure compliance and steady erosion on of the scope for individual professional judgement... Its time to stop, reflect and ask whether there is an alternative way to approach the problem.... Munro 2005:533 Why do child death inquiries? Individuals are held responsible and practice is proceduralised

7. Fatally abused children only represent a small, albeit important, proportion of all abused children. The importance of the tragedy and learning lessons may lie less in the prevention of individual deaths and more on the impact on improved child protection practices affecting a much larger group of children who are abused, but not killed. Falkov 1996:23 Why do child death inquiries? They are a window into the service system

8. Key features highlighted in Seminar: Range of agencies/committees involved The purpose of inquires The methodology of inquiries The participants Individual and group approaches Making a difference The cultural context

9. What will it take? Doing systemic inquires Child, family & individual practice Intra-organisational relationships & systems Inter-organisational relationships & systems Wider community & political understanding & leadership

10. i.e. assisting people to process the death or serious incident professionally & personally, having a voice i.e. reviewing how well people worked within current legal, procedural, practice frameworks. What were the barriers? What are the strengths? What is needed to promote good practice? i.e. attempting to understand, making meaning, and improving practice and systems Child & Family Intra Service system Inter Service system Systemic Inquiry Child & Family Intra Service system Inter Service system Systemic Inquiry Accountability Therapeutic debriefing Reflection and learning Child & Family Intra- organisationa l systems Inter- organisational relationships Individual case workers Systemic Inquiry

11. Child & Family Accountability Reflection & learning Therapeutic debriefing Child & Family acknowledges uncertainty supports feelings planned innovation diverse views = strength collaborative safe power sharing Collaborative learning environment for child death inquiries

12. What happens in the future? Strong will was shown among all jurisdictions to hold regular seminars which, at a national level, will:  Facilitate communication  Strengthen collaboration  Determine trends  Capture issues  Identify learnings  Influence change

13. Contact details for the Office of the Child Safety Commissioner: Mary McAlorum and Kay Warn Level 20, 570 Bourke Street Melbourne 3000 Phone: (03) 8601-5282 or (03) 86015283 Email:mary.mcalorum@ocsc.vic.gov.au or kay.warn@ocsc.vic.gov.au Website:www.ocsc.vic.gov.au Presenters: Dr Judith Gibbs, Independent Consultant Mary McAlorum, Office of the Child Safety Commissioner Kay Warn, Office of the Child Safety Commissioner