Resource Sheet No. 4
August 2009


Fatal child abuse

Compiled by Mel Irenyi and Briony Horsfall
National Child Protection Clearinghouse
Published by the Australian Institute of Family Studies
ISSN 1448-9112 (Online)

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What is fatal child abuse?

Fatal child abuse is defined as the death of a child resulting from acts of physical violence or neglect of a child, perpetrated by a family member or caregiver.

What international statistics are available?

The World Health Organization (2002) estimated that, worldwide, 57,000 children were victims of homicide in 2000, but also stated that many child deaths were not routinely investigated (WHO, 2002). More recent international data are not available.

In the United States, there was an estimated 1,760 child deaths due to child abuse or neglect between July 2006 and June 2007 according to the US Department of Health and Human Services, Administration on Children, Youth and Families (2009) report Child Maltreatment 2007. This equates to 2.35 child deaths due to abuse or neglect per 100,000 children in the population. It was also found that younger children were more likely to be victims of fatal child abuse. United States child maltreatment data indicate that 76% of children who died due to abuse or neglect were less than four years of age.

Like the World Health Organization, the United States Advisory Board on Child Abuse and Neglect recognises that this is an underestimation and reported that a more realistic estimate of child deaths in the United States as a result of abuse and neglect, both known and unknown to statutory child protection services, is about 2,000 per year. This is approximately five children each day (US Advisory Board on Child Abuse and Neglect, 1995).

What information is available in Australia?

It is difficult to obtain accurate statistics about the numbers of children who die from child abuse or neglect in Australia because comprehensive information is not currently collected in every jurisdiction.

According to the most recent national data, in 2003 the leading cause of death among children aged 0-14 years was injury, which is broken down into five subcategories: transport accident, drowning, assault, falls and suicide. In 2003, assault was the third most common type of injury causing death for Australian children aged 0-14 years. It resulted in the deaths of 73 children in 2001-03, compared to 327 deaths of children from transport accidents and 139 drowning deaths. A total of 815 Australian children aged 0-14 years died from injuries in 2001-03 (Australian Institute of Health and Welfare, 2005).

On average, 25 Australian children are killed by their parents each year (Mouzos & Rushforth, 2003).

UNICEF (2003) estimated that of the 30 most economically developed nations, Australia had the 9th lowest rate of child death resulting from child abuse and neglect.

Which states carry out child death reviews?

Detailed information on deaths resulting from child abuse and neglect is not available from all Australian jurisdictions; however, information from jurisdictions that carry out official inquiries into child deaths (also referred to as child death reviews) provides some guidance.

For those states and territories that do collect official statistics, there is a general consensus that such figures under-represent the size of the problem because some child deaths labelled as "accidental deaths" might actually be attributable to child abuse and neglect.

Child Death Review Teams aim to identify strengths and weaknesses in system responses for the benefit of future prevention and action. They do not aim to determine the culpability of alleged offenders or comment on the individual performance of workers, nor do they investigate the causes of child deaths; that role is left to the police and coroner. Child death review teams do not conduct interviews or meet with staff or families of the deceased, but rather rely on document and case note analysis.

New South Wales, the Northern Territory, Queensland, South Australia, Victoria and Western Australia have child death review teams or committees. Reports released by the child death review teams/committees are described and the available data presented below. For those jurisdictions that do not have a publicly available formal and routine fatal abuse reporting mechanism, a description is provided of any other publicly available review or data on fatal abuse.

Australian Capital Territory

A committee was formed to review child deaths that had occurred in the ACT between 1992 and 2003. The purpose was to review all child deaths, and to consider and make recommendations to address systemic social and environmental issues that were associated with children and young people. In 2006, the committee presented its report, which showed that no child or young person known to the child protection department had died as a result of non-accidental injury inflicted by another person during that period (Office of the Chief Health Officer, 2006).

Currently, there are no processes in place for the routine preparation and tabling of an annual report on child deaths in the ACT. However, in 2009, a memorandum of understanding was signed between ACT Health and the ACT Department of Disability, Housing and Community Services (which includes Care and Protection Services), allowing for the joint case review of clients known to both Care and Protection Services and ACT Health. The review process is conducted under the auspices of the ACT Health Clinical Audit Committee. Cases referred to the Audit Committee will include critical incidents, such as the death of an infant or child, and in future, near-miss incidents will also be reviewed. In relation to the death of a child known to Child Protection Services, the committee will provide recommendations for systemic improvements for individual agencies and for improved collaboration between ACT Health and Child Protection Services. Child Protection Services may also engage an external investigator to review a child death in some circumstances (I. Cevallos, Department of Disability, Housing and Community Services, Office for Children, Youth and Family Support, personal communication, 4 March 2009).

Tasmania

In Tasmania, 10 child deaths in 2005 and 2006 involved children known to child protection services (Department of Health and Human Services, 2005). Of the 10 deaths:

Two child death reviews have been conducted since 2006, one involving an infant/child who died of Sudden Infant Death Syndrome and another involving a child known to child protection services. The findings of these reviews remain confidential.

There is currently no mechanism in place for routine group analysis of child deaths and therefore no annual report regarding child deaths. However, the benefits of group analysis of child deaths have been recognised (Department of Health and Human Services, 2009). The Tasmanian Department of Health and Human Services is currently developing a strategic framework to bring together the child death review mechanisms that exist across the state (i.e., coronial, obstetric and paediatric, and child protection) and a working group has been formed to advise government on the establishment of a "strategic review body" (such as a child death review team or committee) for the state (P. Shirley, personal communication, 10 March 2009). The working group is likely to recommend that the "strategic review body" be established through supporting legislation.

New South Wales

There are two sources of reports about child deaths in New South Wales: the New South Wales Child Death Review Team as part of the New South Wales Commission for Children and Young People, and the New South Wales Ombudsman.

The New South Wales Child Death Review Team was established in 1996 and provides comprehensive information on the deaths of all children and young people from birth to 17 years. The purpose of the Child Death Review Team is to prevent or reduce the number of deaths of children and young people in NSW. The 2007 report of the Child Death Review Team provided data on all deaths of children and young people in NSW from January to December 2007. The deaths were reported against various categories - the figures in this resource sheet relate to deaths categorised as fatal assault (NSW Child Death Review Team, 2008).

There were a total of 601 deaths of children and young people aged 0-17 years registered in NSW in 2007, nine of which were caused by fatal assault. These figures can be compared to those recorded in 2006, when 10 young people died. Of the nine fatal assaults in 2007, three involved girls and six involved boys, ranging in age from infancy (under 12 months) to 17 years. Five of the nine deaths were children aged between birth and four years. Six deaths occurred in the context of family relationships, including two children in a murder-suicide incident. In addition to the nine fatal assault deaths, 14 children died in the context of inadequate supervision, including 10 children who drowned in private pools (NSW Child Death Review Team, 2008).

The New South Wales Ombudsman reviews the causes and patterns of deaths of vulnerable children (e.g., those children known to the Department of Community Services, in out-of-home-care, in detention, living in disability accommodation, and who died in suspicious circumstances). The New South Wales Ombudsman (2009) reviewed 162 child deaths that occurred during 2007. This is considerably higher than the 10 fatal assaults identified by the NSW Child Death Review Team (2008) as the Child Death Review Team used strict standards of evidence in determining cause of death. The Ombudsman reported that 43 deaths occurred in the context of abuse, neglect or suspicious circumstances (8 abuse, 11 neglect, and 24 suspicious circumstances). Twenty-eight children were from families who had had contact with the NSW Department of Community Services within three years of their death.

Northern Territory

In November 2007, the Northern Territory Legislative Assembly passed the Care and Protection of Children Act 2007, which included provisions for the establishment of a Child Death Review and Prevention Committee. This legislation commenced in May 2008, and the inaugural meeting of the committee was held in February 2009. The committee is required to establish and maintain a child death register for all child deaths in the NT (and children whose usual residence is in the NT) up to the age of 18 years. The committee is also able to sponsor or conduct research, develop policies, and raise public awareness aimed at reducing and preventing child deaths, diseases and accidents (H. Berry, Northern Territory, Office of the Children's Commissioner, personal communication, 20 February 2009). As the committee held its inaugural meeting in 2009, there has been no report to date for child deaths in the Territory.

Queensland

Since August 2004, the Commission for Children and Young People and Child Guardian has been responsible for the centralised collection and coding of mortality information for deaths of children and young people in Queensland (Commission for Children and Young People and Child Guardian, 2006).

The commission's 2008 annual report of deaths of children and young people reported that from July 2007 to June 2008, 11 children and young people were fatally assaulted (Commission for Children and Young People and Child Guardian, 2008). The overall rate of death from fatal assault from 2007-08 was 1.1 per 100,000 children. Eight children (73%) who were fatally assaulted were aged between birth and four years. The most frequent method of assault was physical violence not involving a weapon (63.6%). A family member was the perpetrator in all fatal assaults, with at least one parent or step-parent involved in killing 10 of the 11 children. Fatal assaults were categorised as fatal child abuse in seven cases. At the time of their death, 9 of the 11 children were known to the Queensland child protection system. An in-depth study of fatal assault and neglect of children and young people in Queensland is expected to be finalised and a report released in 2009.

South Australia

According to the Child Death and Serious Injury Review Committee's (2008) annual report for 2007-08, no child or young person died due to fatal neglect during 2007. Although neglect may not have been determined to be the primary cause of any death, the committee acknowledged that substantial neglect was a concern. One young person, a female aged between 15 and 17 years, died by fatal assault; however, the circumstances were not described in the report. In contrast, six children died of fatal assault in 2006 (Child Death and Serious Injury Review Committee, 2007). At the time of releasing the 2007 report, 16 cases were pending completion of investigations and these included cases of fatal assault or neglect (Child Death and Serious Injury Review Committee, 2008).

During 2007, 29 of the 123 children (23%) who died in South Australia were from families who had had some form of contact with the child protection department within the three years preceding their death. Aboriginal children were particularly over-represented in this group: of the 29 children who died in 2007 and whose families had had some form of contact with Families SA within three years prior to their death, 10 were identified as Aboriginal.

Victoria

In Victoria, external inquiries into child deaths are conducted by the Victorian Child Death Review Committee (2003). The committee is a multidisciplinary independent review body. While the coroner and police deal with matters of criminality and culpability, the committee focuses on cases of child deaths where the child has been involved with the Victorian child protection system at the time of their death, or up to three months before their death.

The aims of the Victorian Child Death Review Committee are to:

In 2008, the Department of Human Services (the statutory child protection service) referred 16 cases of children who had died and were known to child protection to the Child Safety Commissioner for enquiry (Victorian Child Death Review Committee, 2009). The Victorian Child Death Committee completed 14 reviews between April 2008 and March 2009. Twelve of the 14 children had active Child Protection case involvement at the time of their death.

Indigenous children were over-represented in enquiries of children known to Child Protection at the time of death, as 4 out of the 16 children who died in 2008 were identified as Aboriginal. The committee identified the prevalence of parental risk factors in the child deaths reviewed. They found that:

Multiple risk factors were also identified as a concern because 10 out of 14 children had experienced more than two parental risk factors (Victorian Child Death Review Committee, 2009).

From 1996 to 2008, the deaths of 17 children and young people were categorised as non-accidental trauma, amounting to 8% of all Child Protection population deaths. In Victoria, the category of non-accidental trauma included deaths associated with physical abuse and homicide. Thirteen non-accidental trauma deaths involved children who were aged from less than 1 year to 3 years old (Victorian Child Death Review Committee, 2009). The report shows that younger children are historically more vulnerable to death by non-accidental trauma than older children. This is consistent with international data on the greater vulnerability of younger children (Finkelhor & Dziuba-Leatherman, 1994).

Western Australia

In Western Australia, the Child Death Review Committee commenced operation in January 2003. Its role is to analyse the ways in which the Department of Child Protection has engaged with families where the death of a child has occurred and where there has been contact with the department in the previous two years.

The aims of the Western Australian Child Death Review Committee are to:

The committee also functions to identify particular classes of child deaths or related issues that may benefit from further investigation or research. Similar to New South Wales and Victoria, the committee does not aim to determine the culpability of alleged offenders or comment on the individual performance of workers, nor does it investigate the cause of deaths (Western Australian Government, 2007).

Since commencing in 2003, the committee has completed 68 reviews in total (Child Death Review Committee Western Australia, 2008). During the reporting period of July 2007 to June 2008, 30 cases of children who died were recommended for review or determined to warrant review by the committee. A total of 14 reviews were completed during the period. Seven of the 14 children were aged between birth and 3 years and 10 of the 14 children who died were male. The committee did not specify the circumstances of all the 14 child deaths reviewed or whether the cause of death was fatal assault or neglect. Two cases were reported during 2007-08 whereby children who were less than 6 months of age died in circumstances of co-sleeping (see text box). Furthermore, co-sleeping was associated with 16 (24%) of the 68 cases reviewed to date, indicating that unsafe co-sleeping practices have contributed to the deaths of these children.

Between 2003 and 2008, the committee reviewed the deaths of 68 children in Western Australia who were known to child protection authorities:

Safe co-sleeping practices for babies and infants

Some parents co-sleep with their baby or infant as part of their approach to parenting or cultural practices. Parents who choose to co-sleep need to be aware that bringing a baby into an adult bed may be unsafe. Some of the risks include:

Source: Jordan, Sketchley & Bromfield (in press)

Further reading

Lawrence, R. & Irvine, P. (2004). Redefining fatal child neglect (Child Abuse Prevention Issues No. 21). Melbourne: Australian Institute of Family Studies. Retrieved 27 November 2007, from <www.aifs.gov.au/nch/pubs/issues/issues21/issues21.html>.

References

Australian Institute of Health and Welfare. (2005). A picture of Australia's children. Retrieved 26 November 2007, from <www.aihw.gov.au/publications/index.cfm/title/10127>.

Child Death and Serious Injury Review Committee. (2007). Child Death and Serious Injury Review Committee: Annual report 2006-2007. Adelaide: Government of South Australia.

Child Death and Serious Injury Review Committee. (2008). Child Death and Serious Injury Reivew Committee: Annual report 2007-2008. Adelaide: Government of South Australia.

Child Death Review Committee Western Australia. (2008). Annual report 2007-2008. East Perth: Government of Western Australia. Retrieved 14 January 2009, from <www.parliament.wa.gov.au/publications/tabledpapers.nsf/displaypaper/3810445a1c6eee52ae7e0554c825750d0081c3b4/$file/child+death+review+committee+ar+2007-08.pdf>.

Commission for Children and Young People and Child Guardian. (2006). Snapshot 2006: Children and young people in Queensland. Brisbane: Commission for Children and Young People and Child Guardian. Retrieved 7 August 2007, from <www.ccypcg.qld.gov.au/pdf/publications/reports/snapshot2006/snapshot-2006-web.pdf>.

Commission for Children and Young People and Child Guardian. (2008). Annual report: Deaths of children and young people Queensland 2007-08. Brisbane: Commission for Children and Young People and Child Guardian. Retrieved 14 January 2009, from <www.ccypcg.qld.gov.au/pdf/publications/reports/annual_report_dcyp_2007-2008/All-Deaths-AR-Complete.pdf>.

Department of Health and Human Services. (2005). Child death review. Hobart: Department of Health and Human Services.

Department of Health and Human Services. (2009). Child death review. Hobart: Department of Health and Human Services. Retrieved 20 February 2009, from <www.dhhs.tas.gov.au/about_the_department/structure/operational_units/dcyfs/program__and__strategies/child_death_review>.

Finkelhor, D., & Dziuba-Leatherman, J. (1994). Victimization of children. American Psychologist, 49, 173-183.

Jordan, B.,  Sketchley, R., & Bromfield, L. (in press). Specialist practice guide: Infants at risk of abuse and neglect. Melbourne: Victorian Government Department of Human Services.

Mouzos, J., & Rushforth, C. (2003). Family homicide in Australia (Trends & Issues in Crime and Criminal Justice No. 255). Canberra: Australian Institute of Criminology. Retrieved 5 August 2009, from <www.aic.gov.au/documents/9/C/B/%7B9CBFDFE5-F9B2-4FEB-A14A-3166810B564F%7Dtandi255.pdf>.

New South Wales Child Death Review Team. (2008). Annual report 2007. Sydney: NSW Commission for Children and Young People. Retrieved 14 January 2009, from <www.kids.nsw.gov.au/uploads/documents/CDRT2007AnnualReport1.pdf>.

New South Wales Ombudsman. (2009). Report of reviewable deaths in 2007: Vol. 2. Child deaths. Sydney: NSW Ombudsman.

Office of the Chief Health Officer. (2006). Review of ACT child deaths: 1992-2003. Canberra: Office of the Chief Health Officer.

UNICEF. (2003). A league table of child maltreatment deaths in rich nations (Innocenti Report Card No. 5). Florence: Innocenti Research Centre.

US Advisory Board on Child Abuse and Neglect. (1995). A nation's shame: Fatal child abuse and neglect in the United States. Washington, DC: US Department of Health and Human Services.

US Department of Health and Human Services, Administration on Children, Youth and Families. (2009). Child maltreatment 2007. Washington: US Government Printing Office.

Victorian Child Death Review Committee. (2003). Annual report of inquiries into child deaths: Protection and care 2003. Melbourne: Department of Human Services.

Victorian Child Death Review Committee. (2009). Annual report of inquiries into the deaths of children known to child protection 2009. Melbourne: Office of the Child Safety Commissioner.

Western Australian Government. (2007). The Child Death Review Committee: An overview. Perth: Child Protection Roundtable.

World Health Organization. (2002). Child abuse and neglect: Facts. Retrieved 27 November 2007, from <www.who.int/violence_injury_prevention/violence/world_report/factsheets/en/childabusefacts.pdf>.

Authors

At the time of writing, Mel Irenyi was a Research Officer for the National Child Protection Clearinghouse at the Australian Institute of Family Studies. Briony Horsfall is a Research Officer for the National Child Protection Clearinghouse at the Australian Institute of Family Studies and was responsible for the August 2009 update of this resource sheet.

Acknowledgements

The authors wish to acknowledge the work of Katie Kovacs and Nick Richardson for their contributions to an earlier version of this guide.

 

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