Annual Reports

Nov 2023 16

Child Death and Serious Injury Review Committee Annual Report 2022-23

This eighteenth annual report, presented to Parliament by the Child Death and Serious Injury Review Committee, provides a summary of the Committee’s data analyses, reviews of child deaths, and activities undertaken to prevent the death or serious injury of children and young people.

In 2022, 107 children and young people died in South Australia. At the time of writing this annual report, information on causes of death for about a quarter of these child deaths was not available to the Committee. The Committee will publish a more detailed statistical report in 2024.

During the 2022–23 reporting period, the Committee continued to review child deaths in South Australia and to make and monitor recommendations for intervention and prevention on a range of issues, including:

recognition of the cumulative harm created by the longstanding neglect of the needs of vulnerable children
expanding intensive family support services to better protect at-risk children and young people
fundamentally changing the ways in which the needs of Aboriginal infants, children and young people, and their families, are conceptualised and met
the need to develop an effective across-agency response to the neglect of critical medical care needs of children and young people.

The Committee has continued to improve its knowledge and understanding of issues that impact children and young people, build its strategic alliances both within the state and nationally, and develop its database and reporting system. The Committee has also provided project support to facilitate discussions between states and territories with the aim of developing a national child death data collection. The focus over the past twelve months has been on documenting each jurisdiction’s legislation, governance and processes for data collection.

The 2022-23 Annual Report is available for download.

Nov 2022 18

Child Death and Serious Injury Review Committee Annual Report 2021–22

Annual Reports, Statistics | 2 min read

This seventeenth annual report, presented to Parliament by the Child Death and Serious Injury Review Committee, provides a summary of the Committee’s data analyses, reviews of child deaths, and activities undertaken to prevent the death or serious injury of children and young people.

The Committee observed the lowest number of child deaths on record consecutively in 2019 (81 deaths) and 2020 (73 deaths). However, in 2021, 104 children and young people died in South Australia. At the time of writing, information on causes of death for about one quarter of the 2021 deaths was not available due to COVID-19-related delays in systems from which the Committee collects information. Consequently, it is not yet possible to identify potential causes of the increase in deaths in 2021.

During the 2021–22 reporting period, the Committee continued to review child deaths in South Australia and to make and monitor recommendations for intervention and prevention on a range of issues, including:

provision of specialist care to children and young people with poorly controlled, severe or unstable asthma
development of effective across-agency responses to the critical medical care needs of children and young people
the need for co-ordinated and collaborative service approaches to mitigate the risks of severe domestic squalor
changes to standards for providers of education and training to young international students
the oversight of informal placements of Aboriginal children and young people
the management of child deaths and palliation.

Under the auspices of its strategic action plan, the Committee has continued to improve its knowledge and understanding of issues that impact children and young people, build its strategic alliances both within the state and nationally, and develop and implement an improved database and reporting system.

Click to view the interactive report online or download a PDF.

Nov 2021 19

Child Death and Serious Injury Review Committee Annual Report 2020–21

Annual Reports | 2 min read

The sixteenth annual report of the Child Death and Serious Injury Review Committee is now available to read in full.

Of note in this report is the further decrease in the number and rate of child deaths. In 2019, the number of deaths of children and young people was the lowest recorded for fifteen years. In 2020, the number of deaths of children and young people decreased further. Many factors may have contributed to this decline, including the impact of the COVID-19 pandemic.

This year, the Committee used its data to inform a submission to the draft of South Australia’s Road Safety Strategy to 2031 regarding safe restraint of children in vehicles, and the lack of recognition of ‘low speed runovers’. The Committee’s research indicates that low speed runovers, which disproportionately involve large SUVs, may be increasing – four such deaths occurred in 2019 in South Australia.

Recommendations made by the Committee as part of its reviews have included the need for the whole of Government to provide services that reduce the likelihood of parents experiencing the loss of their children – through death or the child’s entry into state care.

The Committee extends its sympathy to all those families, friends and the communities who have lost a child. We trust that this report will assist the efforts of those who work to keep children and young people safe.

Click to view the interactive report online or download a PDF.

Dec 2020 2

Child Death and Serious Injury Review Committee Annual Report 2019-20

Annual Reports | 1 min read

The fifteenth annual report of the Child Death and Serious Injury Review Committee is now available to read in full.

Notably, in 2019, the number of deaths of children and young people was the lowest recorded for fifteen years.

Issues raised in reviews the Committee has undertaken in 2019–20 reflect its concerns for those children and young people who are most vulnerable, including the need for collaborative inter-agency practice to reduce the risk of infants dying suddenly and unexpectedly in vulnerable families.

The Committee continues to pursue effective ways to influence service systems and share the knowledge and understanding gained from its analyses and reviews of child deaths. In the coming months, the Committee will release a series of interactive blog posts which will supplement the analyses presented in this report, and facilitate activities aimed to prevent child deaths and serious injuries.

The Committee extends its sympathy to all those families, friends and the communities who have lost a child. We trust that this report will assist the efforts of those who work to keep children and young people safe.

Click to view or download the report.

Nov 2019 28

Child Death and Serious Injury Review Committee Annual Report 2018-19

Annual Reports | 2 min read

This fourteenth annual report of the Child Death and Serious Injury Review Committee provides a summary of the Committee’s reviews and analyses of child deaths and serious injuries, and the steps it has taken to make and monitor the implementation of findings and recommendations arising from them.

This includes analyses showing that between 2005 and 2018:

deaths due to drowning, a deliberate act by another person, and fire-related deaths all peak in the one to four year age group
transport-related incidents are the most common cause of death for young people aged 15-17 years
twenty-eight percent of children who have died, or their families, had had contact with the child protection system in the three years prior to their deaths.

In the reporting period for this Report, three in-depth reviews were submitted to the Minister for Education:

a review into the death of a young Aboriginal child prompted recommendations about the ways in which the child protection system holds itself responsible and accountable for a child’s safety.
a review into the death of a child with disabilities who was in the care of the State, found that generally, systems had worked well to provide this child with a good quality of life.
a second review into the death of a child with disabilities who was receiving services from multiple agencies, found that each agency worked diligently to try to improve the quality of this child’s life, but that these efforts did not meet this child’s complex needs.

The 2018-19 CDSIRC Annual Report is available for download.

Nov 2018 14

Child Death and Serious Injury Review Committee Annual Report 2017-18

Annual Reports | 1 min read

The Child Death and Serious Injury Review Committee’s thirteenth annual report was tabled in Parliament by the Minister for Education, Hon John Gardner on 13 November 2018.

Figures presented in the Report document the discrepancies in the rate of child death between the regions of South Australia.

Since 2005, more than one in every thousand children in the Far North region died before the age of 18. This is three and a half times higher than the State average.

Also of note is the rate of death of Aboriginal children in South Australia, which is almost four times higher than the rate for non-Aboriginal children.

The 2017-18 CDSIRC Annual Report is available for download.

Oct 2017 31

Child Death and Serious Injury Review Committee Annual Report 2016-17

Annual Reports | 1 min read

In its twelfth Annual Report, the Committee has reported that the rate of child deaths has, on average, slowly decreased since 2005. However, higher rates of death are still occurring for children living in the State’s most disadvantaged areas and for Aboriginal children.

Several of the Committee’s in-depth reviews have focused on young parents whose infants have died and led to recommendations about:

The importance of timely cross-border information-sharing.
The need to support young people under guardianship through the provision of appropriate, trauma-informed services and the extension of guardianship arrangements beyond 18 years.
The provision of ante-natal, birthing and parenting support services for young people.

The Committee has recommended the appointment of a strong and influential advocate for Aboriginal children and young people.

The Committee has provided the Minister for Education and Child Development with a list of the fundamental building blocks for services for children with disability that include respect for the centrality of the child, stable care, active case management, the presence of an advocate and end-of-life planning.

To enhance the safety of children, the Committee has recommended changes to the Plumbing Code that could help prevent serious scalding accidents and an infant safe sleeping campaign that provides information, support and access to portable infant safe sleeping devices.

The 2016-17 CDSIRC Annual Report is available for download.

Oct 2016 31