Held in Melbourne 2-3 June 2008

1. Insights from theAustralasian Seminar on Child Death Inquiries and ReviewsPromoting 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. Why do child death inquires?They just create bureaucratic solutions and demand compliance 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

4. Why do child death inquires?They haven’t improved practice up to this point 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

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. Why do child death inquiries?Individuals are held responsible and practice is proceduralised 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

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

10. Systemic Inquiry 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. assisting people to process the death or serious incident professionally & personally, having a voice i.e. attempting to understand, making meaning, and improving practice and systems Accountability Intra Service system Intra Service system Inter Service system Inter Service system Intra- organisational systems Inter- organisational relationships Child & Family Child & Family Child & Family Reflection and learning Therapeutic debriefing Individual case workers Systemic Inquiry Systemic Inquiry

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

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. Presenters: Dr Judith Gibbs, Independent Consultant Mary McAlorum, Office of the Child Safety Commissioner Kay Warn, Office of the Child Safety Commissioner 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