Ombudsman Report Exposes Systemic Failures in Care for Disabled Brothers

A report by the Queensland Ombudsman has identified systemic failures within Queensland Health in its handling of a case involving two severely disabled brothers who experienced abuse and neglect over two decades. The investigation, which examined the agency's interactions with the brothers between 2000 and 2020, found issues with staff training, information management, and follow-up procedures. The report has led to a series of recommendations for systemic reform.

Report Overview and Context

The Queensland Ombudsman, Anthony Reilly, published the report on Tuesday. It constitutes the third in a series of investigations examining public sector agencies' ability to prevent harm to children with disabilities.

The report was commissioned in response to a specific case involving two brothers, referred to by the pseudonyms Kaleb (born 2000) and Jonathon (born 2003). Both brothers were born in Queensland Health hospitals and had significant global development delay, intellectual disability, autism, and limited verbal communication.

Their case was previously examined during a 2023 public hearing of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability.

Case Background and Timeline

• 2000 & 2003: Concerns about Kaleb's safety were reported to the Child Safety department shortly after his birth. He spent significant periods in foster care during his first three years. Similar reports were made regarding both children after Jonathon's birth in 2003.
• 2005: Queensland Health staff reported concerns to Child Safety after both children missed several health appointments. These concerns were later substantiated as neglect.
• 2005-2015: Over the following decade, the brothers missed multiple specialist medical appointments. The Ombudsman's report found that Queensland Health did not follow up on these missed appointments, and no further reports were made to Child Safety during this period. The Royal Commission was told this non-attendance was evidence of chronic neglect.
• May 2020: Emergency services were called to the brothers' home. They were found malnourished and in poor conditions. Their father was found deceased at the scene.

Key Findings of the Investigation

The Ombudsman's investigation into Queensland Health's role yielded several key findings:

"Effective information sharing between Child Safety and agencies like Queensland Health is crucial for identifying and supporting children in need of protection." — Ombudsman Anthony Reilly

• Staff Training and Guidance: While Queensland Health had developed protocols for identifying and responding to child abuse, the report found staff were not adequately trained to report and escalate child protection concerns and required clearer guidance.
• Information Management Systems: The agency's use of both electronic and paper-based files was found to hinder staff from identifying patterns of harm concerning vulnerable children.
• Systemic Gaps: The report concluded that ineffective systems within the agency exposed vulnerable children to further harm. It highlighted that crucial opportunities for intervention were missed due to a lack of follow-up on missed medical appointments and insufficient information sharing.

Recommendations and Official Responses

The report made several recommendations to Queensland Health, including:

• Providing clearer guidance for staff on reporting child protection concerns.
• Implementing changes to information management systems to allow for cross-checking of concerns.
• Establishing regular audits to identify at-risk children who miss health appointments.
• Considering mandating the use of Child Safety's Child Protection Guide.

In response, Queensland Health Director-General Dr. David Rosengren stated that many of the recommendations would be considered through established policy review cycles. He noted that work is already underway to digitize health records and to consider auditing at-risk children who miss outpatient appointments.

Dr. Rosengren added that Queensland Health would continue working with Child Safety and other partners to strengthen responses to the health needs of vulnerable children and families.

In 2023, Queensland's child safety minister apologized to Kaleb and Jonathon for the decades of violence, abuse, and neglect they suffered.