Annual Report 2020–2021


Committee's Foreword


The Child Death and Serious Injury Review Committee is pleased to present its sixteenth annual report to Parliament. This report is provided under Part 4 of the Children and Young People (Oversight and Advocacy Bodies) Act 2016.

In July 2021, the Committee farewelled its Chair, Ms Meredith Dickson QC. The Committee thanks Meredith for her leadership and commitment to strengthening the Committee’s strategic alliances and expanding the ways in which it contributed to the prevention of child deaths.

In June, the Committee also farewelled two of its long-standing members – Dr Deepa Jeyaseelan and Ms Di Gursansky. These members share a deep commitment to improving the lives of South Australia’s children. Their dedication to the care of children and their expertise will be missed.

This year’s annual report demonstrates the broad scope of the Committee’s work. The Committee has considered the deaths of infants from the perspective of the history of their parents and made recommendations about the services that are needed to support young people whose lives have been impacted by trauma. Using its data about the circumstances of sudden unexpected deaths of infants, the Committee worked with Kidsafe SA, one of its key prevention partners, to host a forum about this matter. Also in conjunction with Kidsafe SA, the Committee has brought to the attention of South Australian policy-makers the need to consider the safety of children in road safety strategies.

One of the Committee’s great strengths is its multi-disciplinary membership. When reviewing the circumstances and cause of each death, members bring their particular knowledge and expertise about the issues confronting families, children and young people, or the challenges faced by services to provide for the needs of every child. The combination of these contributions provides a sound basis for decision-making about systemic issues in the circumstances of a death that, if changed, might prevent the deaths of other children in similar circumstances.

While its work is at times confronting, the Committee believes that much can, and should, be learned from its reviews of child deaths. A major challenge the Committee continues to face is gaining the attention of legislators, policy-makers, and practitioners whose role it is to make a positive difference to the lives of children and young people.

The Committee thanks those agencies that have been willing to demonstrate the capacity to recognise and accept the need for change and embrace the benefit of listening to an independent source of evidence.

Children die from many different causes. Each death is a tragedy, and the Committee extends its sympathy to the families, friends, communities, and professionals who have loved and cared for those children who have died. The Committee hopes that this report assists the efforts of those who work to keep children safe.