Executive Summary



This is the fifteenth annual report of the Child Death and Serious Injury Review Committee.

This report provides highlights of the Committee’s data analyses and review of child deaths and serious injuries, notably:

  • In 2019, the number of deaths of children and young people was the lowest recorded for fifteen years. Encouraging as this is, the Committee will await the 2020 statistics before considering reasons for this decrease.

  • Analyses of child deaths in transport crashes point to the potential for tragic outcomes when children are unrestrained or not properly restrained.

Issues raised in reviews the Committee has undertaken in 2019–20, reflect its concerns for those children and young people who are most vulnerable. Issues include:

  • The need for collaborative inter-agency practice to reduce the risk of death of infants born prematurely, or dying suddenly and unexpectedly, in vulnerable families.

  • The impact of neglect on the quality and length of life of a young person with a chronic health condition.

  • Safety and quality standards that should be in place when children and young people with disability are placed in the care of others.

  • Placement of Aboriginal children and young people that ensures the protection of their safety and wellbeing.

These reviews have raised questions about the ways in which state and non-government agencies deliver services to children and young people, and have the potential to provide service agencies with some insight into preventing failures in their service systems.