Ombudsman Report

Investigation into complaints about assaults of five children
living in Child Protection residential care units
October 2020
Ordered to be published
Victorian government printer
Session 2018-20
P.P. No. 177
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The Victorian Ombudsman pays respect to First Nations custodians of Country throughout Victoria. This respect
is extended to their Elders past, present and emerging. We acknowledge their sovereignty was never ceded.
Letter to the Legislative Council
and the Legislative Assembly
To
The Honourable the President of the Legislative Council
and
The Honourable the Speaker of the Legislative Assembly
Pursuant to sections 25 and 25AA of the Ombudsman Act 1973 (Vic), I present to Parliament my
Investigation into complaints about assaults of five children living in Child Protection residential care
units.
Deborah Glass OBE

Ombudsman
28 October 2020
2 www.ombudsman.vic.gov.au
Warning
This report contains information some may find distressing or uncomfortable. If
you experienced abuse as a child or young person at home or in care, it may be a
difficult reading experience.
The report also contains references to views, policies and practices that may
not reflect the current views, policies or practices of the Community Service
Organisations involved, the Department of Health and Human Services or the State
of Victoria.
If you find the report’s content distressing, please seek support either from the
Department or another agency. If you are not sure how or where to access support,
contact the Victorian Ombudsman for assistance:
Email: enquiries@ombudsman.vic.gov.au
Telephone: (03) 9613 6222 or 1800 806 314 (regional only)
In person: Level 2, 570 Bourke Street, Melbourne.
Our office is wheelchair accessible by lift.
Please note: At the time of publishing this report (October 2020), our office is
closed to members of the public due to the COVID-19 pandemic. If you are reading
this report at a later time, our office may have re-opened. Please call or email us
before visiting to check whether our office has re-opened to visitors.
warning 3
Contents
Foreword 6
Executive summary 8
Why we investigated 8
The children’s experiences 9
Wider issues 12
Recommendations 13
Government and Department responses 15
Background 16
Why we investigated 16
Jurisdiction 17
How we investigated 17
Privacy 19
Child protection and residential care 20

History of child protection in Victoria 20
Victoria’s current child protection
system 20
Residential care 21
Standards for residential care 26
The children’s experiences 29

Quinn 29
Kylie 36
Brittany 47
Avery 55
Alex 63
Wider problems and potential solutions 71

Wider problems 71
Potential solutions 76
Conclusions 82
Opinion 84
Recommendations 86
Appendix 1: CSO and Victoria Police

responses 92
Appendix 2: Incident reporting 106
contents 5
Foreword
‘What’s the point of moving a child from a place that is regarded as not safe, but plac[ing]
that child into another place that is also not safe?’
– ‘Kylie’
This report tells the stories of five young people Some were given psychotropic drugs to
in State care. While in residential care each manage their behaviour. In the disability sector
said they had been physically and sexually this is known as chemical restraint and required
assaulted. All were moved multiple times. to be carefully controlled. No such controls
exist in residential care. One told us: ‘I was on so
A teenage girl at risk of sexual exploitation much medication, I was that slow, it’d take me
was reportedly raped by three men when two minutes just to answer a question.’
she absconded from her residential care unit.
She missed two years of school while in care Their stories are shocking. They are also
and is now so far behind she says she is too painfully sad. These young people had lived
embarrassed to return. difficult lives before they went into care,
which may have been as a result of family
A traumatised teenager began drinking, using violence, parental substance abuse or other
drugs and attempting self-harm. She was raped factors causing their complex and challenging
by an adult man months after going into care. behaviours. Residential care is, rightly, a last
An Aboriginal girl said some weeks after resort when neither parental, kinship or foster
arriving at the unit, a local drug dealer was care is appropriate or available. But they were
giving her ice. The Police are investigating her all damaged further by their experience.
allegations of rape, although she reportedly The experiences of the five children in this
fled before a forensic examination could be report are not new or isolated: in the last
conducted. Her cultural plan, intended to decade, numerous independent bodies
support and connect her to her community, have warned of significant and systemic
took over a year. problems with the residential care system. The
A transgender girl told us her experience in Commission for Children and Young People,
residential care destroyed her life. Her sexual in in its most recent report on out-of-home
identity was deemed a risk to others and her care, found it to be ‘often unsafe for children
female items were taken away from her. She and young people and places them at an
said she was continually sexually assaulted by unacceptable risk of harm’.
another resident. The Department of Health and Human Services
A non-binary child was the subject of multiple acknowledges that children in residential care
reports of sexual assault. He started using ‘are often those who have experienced the
drugs, became involved in criminal offending greatest level of trauma and … require the
and missed a year of school while in residential most expert therapeutic care and support’. It
care. His relative is worried he has been ‘set up recognises that Aboriginal young people face
for failure’. the added impact of intergenerational trauma
and disconnection from culture.
Current legislation requires the Department, These failures are not the result of deliberate
and the organisations who deliver services on disregard for the welfare and safety of the
its behalf, to give effect to the ‘best interests’ children, either within the Department or the
of the child. Our charter of human rights Community Service Organisations. They stem
legislation also emphasises this, and the right of from a system that is neither resourced nor
children both to be safe and feel safe. structured to address the multiple complex
demands being placed on it.
Yet despite the numerous critical reports,
solid legislative framework and indeed, the There are practical solutions, and we put
good intentions of the many hardworking forward two: moving from a four-bed
and dedicated professionals who work in the residential care model to a two-bed model
system, it continues to fail. to support better placement decisions and
therapeutic care. Establishing an independent
Those working in the system told us of the advocate for children in care, which we believe
pressures to take children, of placements sits well with the current functions of the
based on the ‘least-worst’ option rather than Commission for Children and Young People.
the best interests of the child, even where the These are major reforms that will cost money,
match was risky or unsafe. That placement but as these cases show, doing nothing may
decisions were dictated by the availability of well come at a greater cost.
beds. That the system was not designed or
resourced to deal with complex needs and I welcome the Government’s acceptance in
behaviours of concern. That the Department principle of my recommendations, and will
is simply too busy dealing with ‘the crisis of report further on their implementation in
the day’. Community Service Organisations practice.
told us vital information may not be provided
with the placement, and of the pressure by the Nearly a thousand Victorian children lived in
Department to ‘fill targets’. residential care at some time in the last year.
My profound hope is that this is not simply
These cases expose the dark underbelly of our the latest in a long list of critical reports, from
society, that perhaps many of us would rather which little seems to change.
not see. Troubled, sometimes violent families,
children exposed to trauma or substance abuse, Deborah Glass
needing the State to give them a safe home Ombudsman
– but they end up more damaged, with even
greater odds to overcome to lead meaningful
and productive lives. Young people harmed
by residential care - not only at a huge cost to
themselves and their families, but ultimately
also to the State.
foreword 7
Executive summary
Why we investigated 6. In light of the common themes in the five
complaints, the Ombudsman decided to
1. If it is not safe for Victorian children to live investigate:
at home and there are no family or foster
carers available, the Department of Health • the immediate safety of the children
and Human Services Child Protection still in residential care
places children in residential care. • the suitability of the children’s
Residential care involves units (usually placements
modified houses) where up to four children • the care and supervision of the
live under the care of organisations known children
as Community Service Organisations
(‘CSOs’) which operate under a contractual • responses to the alleged assaults and
arrangement with the State Government. other major incidents involving the
children.
2. References to children in this report
include children and young people up to 18 7. The investigation looked at the actions
years. and decisions of Child Protection and the
Department, which funds and regulates
3. In 2019-20, 925 children spent time in the CSOs.
residential care. These children tend to
have complex needs. The Department’s 8. It also looked at the CSOs involved in
website acknowledges they: caring for the children at the time of the
alleged assaults and incidents:
are often those who have experienced
the greatest level of trauma and who, • Child and Family Services Ballarat Inc
therefore, require the most expert (‘CAFS’)
therapeutic care and support.
• Uniting (Victoria and Tasmania)
4. Children in care have the right to ‘be Limited (‘Uniting’)
safe and feel safe’. But, between July • Berry Street Victoria Incorporated
2018 and March 2019, the Ombudsman (‘Berry Street’)
received complaints alleging five children
• Victorian Aboriginal Child Care Agency
were victims of multiple physical and
Co-operative Limited (‘VACCA’)
sexual assaults in residential care, either
by other children in care or people in the • Anglicare Victoria (‘Anglicare’)
community. Some of the assaults have • Junction Support Services Inc
been proven in court or are currently (‘Junction’).
before the courts. In other cases, there
was insufficient evidence for Police to take
matters further, or the assaults were not
reported or recorded.
5. The complaints all raised questions about

the placement, care and supervision of the
children by the Department and its Child
Protection unit (‘Child Protection’) and
particular CSOs.
The children’s experiences
9. Residential care is meant to provide a safe 10. The evidence records assaults or alleged
place for children who cannot live safely at assaults against all five children while
home. In the case of these five children, the they were in residential care. It also shows
investigation found that the system failed. the behaviour of the children grew more
problematic after they went into care.
Quinn
Quinn spent three years in residential care from 2008 to 2011, when she was a teenager. In
2019, she contacted the Ombudsman to say she had been assaulted by an older boy in her
residential care unit and had not received a proper response from the Department.
Quinn had been diagnosed with various disabilities at the time, including an autism spectrum
disorder. She was transitioning from male to female identity.
The evidence shows:
• Child Protection placed Quinn in a CAFS unit with an older teenage boy with a known
history of violent outbursts.
• There were many recorded incidents of threatened or actual violence between the pair.
• Child Protection knew about the incidents. It did not move either child until almost two
years later, after the boy reportedly repeatedly punched Quinn to the face and head and
was charged by Police.
• Quinn later disclosed the boy ‘constantly’ sexually assaulted her by grabbing her genitals.
CAFS did not investigate the allegations nor notify Police – so the allegations remain
unproven. CAFS also did not refer Quinn for counselling.
• It appears that Quinn may have been medicated to try to control her behaviour.
• Quinn was not allowed to have female clothes or items at the CAFS unit. Later, her sexual
identity and behaviours were apparently deemed a risk to others.
executive summary 9
Kylie
Kylie is a young Aboriginal woman who has been in residential care since 2018, when she was
14 years old. Her mother contacted the Ombudsman with concerns about Kylie’s care. She
said Kylie had been raped while away from her residential care unit and she feared for her
daughter’s safety.
The investigation found that since going into residential care, Kylie lived in three different units
managed by Uniting, Berry Street and VACCA. The evidence shows:
• Kylie began using drugs after going into residential care and started leaving her unit and
meeting older men.
• Around seven weeks after going into residential care, Kylie told workers she had
been raped by an adult man in a laneway. In early October 2020, Police advised the
investigation into this alleged assault is ongoing.
• Other children in the units also allegedly assaulted Kylie.
• Berry Street and VACCA said Child Protection pressured them to take Kylie, even though
there were risks involved in placing her in their units.
• Child Protection is meant to give Aboriginal children a cultural plan to support their
connection to their heritage and culture within 16 weeks of going into care. It did not give
Kylie her plan for 53 weeks.
Brittany
Brittany is in her teens and has been in and out of residential care since 2018, when she was
11 years old. Her records describe concerning behaviours, including self-harm, and say she is
at risk of sexual exploitation. In January 2019, a family friend reported to the Ombudsman that
Brittany was raped by three men while she was away from her residential care unit.
The investigation found Child Protection had moved Brittany many times because of her
needs and behaviours. It focused on her first two residential placements with Berry Street and
Anglicare. The evidence shows:
• Berry Street accepted Brittany in one of its units with an older girl with a history of
significant mental health issues. It thought the girl would act like an older sister. But Brittany
started mimicking the older girl’s behaviours, including self-harming and misusing drugs.
• Three months later, a Berry Street worker witnessed the two girls kissing, and Child
Protection agreed to move Brittany.
• After Brittany moved to an Anglicare unit, Anglicare accepted another girl who was also
at risk of sexual exploitation. They started running away and Brittany told workers she
was getting explicit text messages from men.
• Brittany later told workers she had been raped twice – once by an adult man in an
apartment, and another time by three adult men after she and the other girl ran away at
night. Regarding the first alleged rape, Police said Brittany did not make a statement and
there were insufficient details for it to investigate. The second alleged rape is before the
courts.
Avery
Avery is a young woman in her teens who has been in residential care since 2018, when she
was 13 years old. She has been diagnosed with an autism spectrum disorder and complex
behavioural disorders. She lived in two different Berry Street units during her first year in
residential care.
In 2019, Avery’s mother contacted the Ombudsman saying that Avery had been raped by an
adult man while away from her residential care unit. She also said Avery had started using
illegal drugs and self-harming. The investigation found:
• At first, Avery was meant to be the only child placed in her unit because of her complex
needs and behaviours.
• Berry Street said Child Protection pressured it to accept other children in the unit. After
this, Avery’s behaviour deteriorated and she began using drugs.
• Around five months after going into care, Avery was raped by an adult man at his home.
Police told the investigation the man was found guilty at court and is currently appealing
his sentence. Avery has since been hospitalised many times after self-harming.
• Avery also reported that one of the other children in her unit assaulted her three times.
• Child Protection and Berry Street moved Avery to another Berry Street unit where she
was the only child. However, problems continued.
• Berry Street told the investigation there are growing numbers of children with complex
disabilities in residential care. It submitted the system was not designed for these children
and more support is urgently needed.
Alex
Alex is a young person in his teens with a complex history and behaviours, including mental
health conditions. He identifies as non-binary but prefers to be referred to using male
pronouns. One of his family members told the Ombudsman that Alex reported he was raped
by another boy shortly after going into residential care. The investigation found Alex has been
in and out of residential care since early 2019. It focused on Alex’s first placement with Berry
Street and two later placements with Junction. The evidence shows:
• At first, Child Protection placed Alex in a Berry Street unit with three other boys. Alex told
Child Protection he was anxious because he had been sexually assaulted by adolescent
boys in the past.
• Records show unit workers allowed a younger boy to stay in Alex’s room overnight.
Although workers checked on the boys regularly, Alex later said the boy raped him. Police
advised it did not lay charges and Berry Street said its own internal investigation did not
substantiate the sexual assault.
• After Alex moved to a Junction unit, Child Protection and Junction placed a teenage boy
with a history of criminal offending in the unit.
• Alex and the other boy started running away together and using drugs.
• Alex was allegedly seriously assaulted by someone he said was his drug dealer, and spent
more than 12 hours in hospital.
executive summary 11
Wider issues 17. Supervision in some cases was inadequate
and staff were sometimes unclear about
11. Evidence shows the experiences of the the children’s safety plans, which are
five children are not new or isolated. meant to be implemented when a child
Over the last decade, many oversight does not return to their unit.
bodies have warned of significant and
systemic problems with the residential care 18. CSOs sometimes lacked critical
system – this office, the Victorian Auditor- information about the children to assist
General’s Office, the Royal Commission workers in providing informed care and
into Institutional Responses to Child Sexual support.
Abuse, the Institute of Child Protection 19. Child Protection’s policy frameworks rely
Studies and the Victorian Commission for on Care Teams and plans to manage risks
Children and Young People (‘CCYP’). to children and coordinate responses.
12. This investigation identified several wider However, there was sometimes confusion
issues across the five cases. between Child Protection and CSOs about
who was meant to lead Care Teams or
planning.
Placement pressures
13. The evidence shows Child Protection and 20. There were also multiple examples of
the CSOs knew there were risks involved CSOs failing to engage services to address
in the placements of these children, either children’s needs and behaviours.
before they moved in or soon afterwards.
Incident reporting
14. The investigation found these problems
were not the result of deliberate disregard 21. The five cases also demonstrate ongoing
for the welfare and safety of the children. challenges with Child Protection’s incident
In some cases, the CSOs expressed report and response system.
concerns about the suitability of proposed 22. The five children in this report experienced
placements. However, they told the multiple incidents that required an incident
investigation they could not always resist report, including alleged assaults and
‘pressure’ from Child Protection to take the absconding. The CSOs complied with
children, even when the ‘match’ with other incident report requirements in some
children may be risky or unsafe. cases but, in others, there is evidence
15. Child Protection representatives and the that workers failed to complete incident
Department spoke of a stretched system reports, incorrectly categorised incidents
in which Child Protection workers are as ‘non-major’, and failed to notify Police
forced to make ‘least-worse’ decisions of possible offences against children. The
for children. Placement decisions were Department identified and corrected these
dictated by the availability of beds, rather problems in some cases, but not all.
than children’s best interests. 23. The investigation observed there is also
confusion about what constitutes a report
Level of care to Police. At times, CSOs seemed to have
16. The five cases also raise questions about conflated a police report with a formal
the level of care available for children with victim statement: while the latter must
complex needs and behaviours. be made by the victim, anyone can make
a police report. There were also issues
with the way contact between Police and
agencies was documented.
Cultural support and planning for LGBTIQ support
Aboriginal children
30. Two of the five children in this report –
24. In Kylie’s case, Child Protection and Quinn and Alex – experienced problems
two of the CSOs failed to meet some of in residential care because of their gender
the requirements designed to support identity.
Aboriginal children’s connection with
culture and community. Some of 31. The investigation acknowledges Quinn
these issues were not addressed until was in residential care some 10 years ago.
Kylie moved to VACCA, an Aboriginal CAFS says it has since developed more
Community Controlled Organisation. inclusive practices. Alex’s more recent
experience in 2019, when he was placed
25. The VACCA representative said at in a unit with children who were likely to
interview that the failures in Kylie’s case target him, suggests there is still room for
are not isolated. They expressed frustration improvement.
that plans are often delayed and do
not seem to be a priority for Aboriginal 32. The investigation did not hear evidence
children. about the experiences of other LGBTIQ
children in residential care. However, it notes
26. This view is supported by other complaints that during the period under investigation,
to the Ombudsman and CCYP’s 2015 there was little written guidance for Child
report on residential care, “…as a good Protection or CSO workers about how to
parent would…”, which found that: support LGBTIQ children.
[the] current residential care system can
contribute to the isolation of Aboriginal Recommendations
children from their culture and community.
33. The investigation explored two key
Medication and chemical restraint potential solutions to part of the problems
identified in evidence and recommended:
27. Three of the five children in this report –
Quinn, Avery and Alex – had evidence in • a new two-bed residential care model
their files suggesting they may have been • an independent advocate to promote
medicated to manage or control their the rights of children in care.
behaviour.
28. Use of ‘chemical restraints’ carries human A two-bed residential care model
rights implications. In the disability 34. Multiple witnesses agreed that the State
sector, it is subject to regulation and Government needs to move away from the
oversight to protect the rights of people current four-bed model of residential care.
with disabilities. Registered disability
providers must obtain authorisation from 35. The investigation heard the four-bed model
the Department before using chemical is not in the best interests of children
restraints. with such complex histories and needs.
The Department acknowledged that the
29. The investigation identified no such laws placement in one house of four unrelated
or protections for children in residential children with adverse life experiences,
care. In the three cases in this report, Child trauma and behaviours of concern:
Protection and the CSOs investigated
could not be sure if the children were given may result in a high level of incidents that
impact on children’s safety, their exposure
medication for this purpose. to further trauma and the quality of care
they receive.
36. The Department also advised that while 42. Victoria also has two external bodies
demand for residential care services is with an oversight role - CCYP and the
increasing, the number of beds have Ombudsman. However, there is no
remained the same, making placement independent person who regularly visits
matching even more challenging. individual children in care and advocates
on their behalf. Such offices exist in other
37. The Department has been considering contexts. South Australia’s Office of the
the benefits of moving the residential Guardian for Children and Young People
care system from a four-bed model to a advocates for the rights of children in care
two-bed model. It said this model would in that state. In Victoria, the Office of the
provide capacity for individualised and Public Advocate plays a similar advocacy
intensive responses to children, with the role for people with a disability.
support of mental health clinicians, family
workers and community workers. It also 43. The Ombudsman recommends
said it would provide for better matching establishing an independent children’s
of children in placements, stability and advocacy function within the CCYP.
a sense of belonging for children, and
more opportunities to engage with family, Other recommendations
community and education.
44. The Ombudsman also made
38. The Ombudsman recommends conversion recommendations to:
of standard four-bed residential care
• regulate the administration of chemical
units to therapeutic two-bed units
restraints to children in residential care
with enhanced access for the children
to services, particularly mental health • ensure all alleged physical and sexual
and education, while maintaining some assaults of children in residential
capacity in the system for larger groups care are reported to Victoria Police,
(ie siblings). regardless of whether the victim wants
to make a statement, and recorded
An independent advocate for children in in the systems of Police and the
care reporting agency
39. The investigation also considered practical • require that the Department conduct
ways to protect the rights and interests of a review of the children in this report
children in residential care before problems who remain in residential care to
occur. address the deficits in care that were
identified.
40. In these five cases, the children’s files and
other evidence shows the children or their
families often voiced early concerns with
Child Protection or CSO workers, but with
little success.
41. The Department and the CSOs have

internal complaints systems available for
children and families. In these cases, they
were not effective ways to promote the
children’s interests.
Government and Department
responses
45. On 21 October 2020, after reviewing the
final draft report, the Minister for Child
Protection responded on behalf of the
Victorian Government and accepted all of
the recommendations made to Ministers.
The Minister noted policy and budget
would need to be examined to develop
and implement some of the proposed
solutions.
46. The Minister also commented on the

significance of the investigation, ‘which
details the distressing circumstances for
these five young people’ and said the
report:
highlights a range of issues that contributed
to an unsatisfactory level of care and safety
for some of Victoria’s most vulnerable
children.
47. In May 2020, after reviewing the draft

report, the Secretary of the Department
stated:
The experiences of the five young people,
as detailed in your report, are concerning.
The Department and Community Service
Organisations are committed to reform
the residential care system to provide
intensive support and stabilisation for
young people with complex needs, and
to support their transition to family based
care and independence.
48. After reviewing the final draft report

and having an opportunity to consider
the proposed solutions, the Secretary
accepted all of the Ombudsman’s
recommendations, noting some require
budgetary and policy consideration.
Background
Why we investigated 56. In light of the common themes, the
Ombudsman decided to investigate:
49. Between July 2018-March 2019, the
Ombudsman received five complaints • the immediate safety of the four
alleging children had been assaulted while children still in residential care
in residential care. • the suitability of the five children’s
placements
50. References to children in this report
include children and young people aged • the care and supervision of the
up to 18 years. children
• responses to the alleged assaults and
51. Residential care involves units (usually other major incidents involving the
modified houses) where up to four children children.
live under the care of organisations known
as Community Service Organisations 57. The investigation looked at the actions
(‘CSOs’), which are contracted with the and decisions of Child Protection and the
State Government. The Department Department, which funds and regulates
of Health and Human Services Child the CSOs.
Protection places children in the units
if it is not safe for them to live at home, 58. It also looked at the CSOs. There were
and there are no family or foster carers six CSOs involved with the children at
available. these times (some of the children lived in
multiple residential care units managed by
52. The Department’s website says children different CSOs). They were:
in care have the right to ‘be safe and feel
safe’. But the complaints claimed the five • Child and Family Services Ballarat Inc
children were victims of multiple assaults, (‘CAFS’)
either by other children in care or people in • Uniting (Victoria and Tasmania)
the community. Limited (‘Uniting’)
53. The first complaint was from an adult • Berry Street Victoria Incorporated
who lived in residential care around 10 (‘Berry Street’)
years ago. She said an older boy in her • Victorian Aboriginal Child Care Agency
unit sexually assaulted her, and she never Co-operative Limited (‘VACCA’)
received an adequate response from the • Anglicare Victoria (‘Anglicare’)
Department. She said she experiences
ongoing trauma and has been suicidal at • Junction Support Services Inc
times. She was worried about children in (‘Junction’).
care now. 59. The investigation did not look at all aspects
54. The four other complaints involved of residential care. The Commission for
children who were still in residential care. Children and Young People (‘CCYP’) is the
They were made by concerned family or specialist body for these matters and was
friends, who alleged the children had been conducting a systemic inquiry into the
sexually or physically assaulted while in lived experience of children in out-of-home
care. care during the investigation.
55. The complaints all raised questions about

the placement, care and supervision of the
children by the Department and its Child
Protection unit and CSOs.
60. The investigation also did not investigate How we investigated
the alleged assaults, as these are criminal
matters. Some of the assaults have been 66. On 15 April 2019, the Ombudsman notified
proven in court or are currently before the Minister for Child Protection and
the courts. In other cases, there was the Secretary of the Department of her
insufficient evidence for Police to take intention to investigate the complaints.
matters further, or the assaults were not
reported or recorded. 67. The Ombudsman notified the six CSOs
between 24 and 26 April 2019. The
61. Rather, the investigation looked at the Ombudsman sent an additional notification
experiences of these five children to to Berry Street on 2 August 2019, after
identify possible wider problems with the investigation identified Berry Street
residential care. provided care to an additional child.
68. The people who complained to the

Jurisdiction Ombudsman were notified between
26 and 29 April 2019.
62. Under the Ombudsman Act 1973 (Vic), the
Ombudsman may investigate administrative 69. The investigation considered Department
actions taken by or in an authority. The Act policies, Annual Reports and practice
defines an 'authority' as a department, such guides applicable at the time including:
as the Department of Health and Human
Services. Child Protection is a business unit • Child Protection Manual
in the Department. (‘Child Protection Manual’)
• Program requirements for
63. An ‘authority’ also includes a 'specified
residential care in Victoria (October
entity' set out in Schedule 1 to the Act. Item
2016) (‘Residential Care Program
19 of Schedule 1 includes a ‘registered
Requirements’)
community service’ (CSO) in accordance
with the Children, Youth and Families Act • Program requirements for the delivery
2005 (Vic). The six CSOs are registered of therapeutic residential care in
community services under that Act. Victoria (October 2016) (‘Therapeutic
Care Program Requirements’)
64. Four of the complaints were investigated
• Placement Coordination and
pursuant to section 15B of the
Placement Planning Framework
Ombudsman Act, which empowers the
(December 2012) (‘Placement
Ombudsman to investigate complaints
Framework’)
made by ‘directly affected’ persons (in this
instance, the children or their families). • Placement Coordination and
The fifth complaint was made by a family Placement Planning Manual
friend and the Ombudsman investigated (December 2012) (‘Placement Manual’)
that matter using her ‘own motion’ powers • Client Incident Management Guide
pursuant to section 16A of the Act. Policy Update 1-2020 (20 December
2019, effective 3 February 2020)
65. The Ombudsman Act also empowers
(‘Incident reporting Policy update’)
the Ombudsman to investigate whether
an administrative action is incompatible • Client Incident Management Guide
with, or an agency has failed to give Client Incident Management System,
proper consideration to, a right set out November 2017 (‘Incident reporting
in the Charter of Human Rights and guide’)
Responsibilities Act 2006 (Vic) (‘Charter of
Rights Act’).
background 17
• Incident reporting instruction 70. The investigation also:
(March 2008) (superseded)
• sought written responses from the
• Responding to allegations of physical Department and the six CSOs
or sexual assault (August 2005)
(superseded) • reviewed the five children’s files
• Human services standards evidence • examined relevant CSO policies

guide (September 2015) (‘Human • obtained data from the Department
Services Standards’) and CCYP
• Wungurilwil Gapgapduir Aboriginal • reviewed relevant academic research
children and families agreement - • attended a national child protection
a partnership between the Victorian forum focused on the care of
Government, Victorian Aboriginal Aboriginal children
communities and the child and
family services sector (April 2018) • reviewed other significant reports
(‘Wungurilwil Gapgapduir’) on child protection by CCYP, the
Victorian Auditor-General, the
• Office of the Senior Practitioner, Royal Commission into Institutional
Practice Advice: Important information Responses to Child Sexual Abuse
about medications prescribed for the (2013-2017) and public submissions
primary purpose of the behavioural being made to the current Royal
control of a person with a disability Commission into Violence, Abuse,
(February 2008) (‘Practice Advice Neglect and Exploitation of People
restrictive interventions’) with a Disability
• Administration of medication • conducted enquiries into new
(Advice, Child Protection Manual complaints to the Ombudsman during
22 December 2017) the investigation, mostly from other
• Out-of-Home Care Education children about their safety and stability
Commitment (2018) in residential care
• Minimum qualification requirements • obtained information from:
for residential care workers in Victoria o Police and examined the Victoria
(December 2018) Police Manual, Crime and event
• Protecting children: Protocol between reporting and recording
Department of Human Services – (29 March 2019)
Child Protection and Victoria Police o CCYP
(2012) (‘Child Protection and Police
Protocol’) and Addendum: Preventing o WorkSafe Victoria
sexual exploitation of children and o Department for Child Protection,
young people in out-of-home care South Australia
(2014). o a child psychologist who worked
with one of the children
• interviewed eleven witnesses. Ten
of the interviews were conducted
under oath or affirmation. Two
witnesses were accompanied by a
legal representative and two were
accompanied by a support person.
71. During the evidence-gathering phase, the Privacy
investigation interviewed the adult who
made the first complaint, but not the four 76. This report contains sensitive personal
children still in care. The investigation information about the five children and
contacted the children, through the their families.
Department, with written information
about the investigation. The children were 77. The report has changed the names of the
invited to ask questions, raise concerns or children to protect their identities. It has
contribute. None made contact at the time. also left out some dates and other details
that might identify the children and their
72. The Ombudsman was guided by the families.
civil standard of proof, the balance
of probabilities, in determining the 78. After preparing the draft report, the
facts of this investigation - taking into investigation consulted the young adult
consideration the nature and seriousness and family members who had complained
of actions and decisions and the gravity and shared relevant excerpts of the draft
of the consequences that may result from report with them. The investigation also
forming any adverse opinion. invited the four children to contact the
investigation if they wished to discuss or
73. This report contains adverse comments view the report. Two of the children made
about the Department and the six CSOs. contact and the report reflects their views.
74. In accordance with section 25A(2) of 79. The report also contains information
the Ombudsman Act, the investigation about other children in residential care
provided these organisations, and Police, and people in the community who were
with a reasonable opportunity to respond involved in the reported assaults. Some
to the material in a draft version of this of the assaults have been proven in a
report. This report fairly sets out their court, while others remain as unproved
responses. allegations. The Ombudsman has formed
no opinion about the guilt of any person in
75. In accordance with section 25A(3) of relation to any alleged criminal offence.
the Ombudsman Act, any other persons
who are or may be identifiable from
the information in this report are not
the subject of any adverse comment or
opinion. They are named or identified in
the report, as the Ombudsman is satisfied
that:
• it is necessary or desirable to do so in
the public interest, and
• identifying those persons will not
cause unreasonable damage to those
persons’ reputation, safety or well-
being.
background 19
Child protection and residential care
80. The experiences of the five children in 85. Victoria did not establish a statutory child
this report require some understanding of protection service until 1985. Until 1994, it
Victoria’s child protection and residential operated as a ‘dual-track’ system, where
care systems. This section explains the Police dealt with cases that could not be
origins and structure of these systems and handled by the child protection service.
the Department’s and CSOs’ obligations to
keep children safe and well. 86. Many past child protection practices were
damaging to children and communities,
81. The history of Child Protection services particularly Aboriginal communities. In
is based on information in the Australian 2008, the Federal Parliament issued an
Institute of Family Studies, History of child apology on behalf of the nation to the
protection services (2015). stolen generations of Aboriginal children
who were removed from their families,
History of child protection in communities and land. The following
year, the Federal Government also made
Victoria a national apology to children who
82. Child protection services in Victoria date to experienced abuse in out-of-home care.
the late nineteenth century. Post-colonised
Australia and similar societies considered Victoria’s current child
children to be the property of their protection system
parents. In 1870s New York, for example,
a concerned authority had to seek 87. Victoria’s current child protection system
protection for a 10-year-old girl with the is the result of reforms introduced by the
help of animal protection workers, as there 2005 Children, Youth and Families Act.
were no laws to protect children from Amongst other things, the Act focuses on:
cruelty. The only options for ‘abandoned’
children were orphanages run by religious • early intervention and prevention for
and volunteer organisations. struggling families
• community-based services and
83. Victoria’s first child protection service was support for families
established in 1894. The service was run by
a non-government service, the Victorian • creating timely and permanent
Society for the Prevention of Cruelty to placements for children through case
Children. The service focused on young planning (ideally at home)
children and severe neglect and physical • recognition of the continued impact of
abuse. child protection policies on Aboriginal
communities and the importance
84. From the 1960s, public awareness about of maintaining Aboriginal children’s
the physical abuse of children grew due connection to culture and community.
to medical research and media attention
about what was then called ‘battered-child 88. The system faces significant pressures. The
syndrome’. Into the 1970s and 1980s, there Department advised its Child Protection
was a move away from institutionalisation service received 122,179 reports about
of children. Foster care and smaller group children’s safety and wellbeing in 2019-20.
homes became the preferred options Nearly 35,000 of these reports required
for children who could not live at home. formal investigation.
The concept of child abuse also began
to expand from the 1980s and 1990s, to
include sexual and emotional abuse.
89. When a child cannot live safely at home, Agencies and organisations
Child Protection has four options for
Department of Health and Human Services
placing children in out-of-home care:
Child Protection
• kith or kinship care, where children 94. The Child Protection service investigates
live with friends or family such as reports of child abuse; refers children and
grandparents families to services; takes matters before
• foster care, where children live with the Children’s Court if children cannot live
approved community members or safely within their families; and arranges
families with whom they have no pre- and oversees placements for children in
existing relationship care when they cannot live at home.
• permanent care, where children live in 95. In 2019-20, Child Protection employed
an ongoing arrangement with a carer more than 2,000 Child Protection
who also becomes the child’s guardian Practitioners in four divisional offices and
• residential care, which is the focus of its statewide services group. The statewide
this report. services group, introduced in March 2020,
is responsible for delivering After Hours
Services, Secure Welfare and Intake (where
Residential care reports are made).
90. Child Protection uses residential care when
96. Each Child Protection divisional office
home-based options such as kinship and
has a specialist unit called the Placement
foster care are not available.
Support and Placement Coordination Unit
91. Residential care involves placing children (‘Placement Unit’). The Placement Units
into residential care units in the care of coordinate placements in residential care.
paid workers. Residential care units in A Child Protection Practitioner provides
Victoria are usually modified houses that the Placement Unit a ‘Placement Referral’,
cater for up to four children. There are two which lists the child’s needs and the
types of units: standard and therapeutic. purpose of the placement. The Placement
Unit then negotiates with CSOs to find a
92. Therapeutic units deliver specialised care residential care unit that matches those
from a trauma-informed perspective, with needs.
a focus on healing through relationships
and emotional bonds with trusted carers. 97. For Aboriginal children, Child Protection
These units do not provide any therapeutic is required to consult Aboriginal services
services directly to the children. Instead, such as Lakidjeka, a specialist Aboriginal
clinical specialists provide advice and consultancy service within VACCA.
support to workers in the units on a part-
98. For placements in therapeutic units, Child
time basis.
Protection establishes specialist referral
93. The Department also operates a Secure and selection panels. These include CSO
Welfare service, where children at Program Managers, therapeutic specialists,
substantial and immediate risk of harm live Placement Unit Managers, Child Protection
for short periods in locked single-sex units. representatives and Aboriginal services as
relevant.
child protection and residential care 21

99. Figure 1 shows a simplified placement process when a child is placed in residential care.
Figure 1: Example of a residential care placement process
Child Protection decides Child Protection makes Court makes

child needs placement – application to court; notifies Protection Order
no kinship carers Placement Unit possible
placement needed
Court returns child Child Protection applies Child
home or to kinship to change Protection Protection
carer Order to return child
home or to kinship carer
Consult
for
Aboriginal
child
Support
to
Residential Care offered reunify
if no foster carers or
Placement Unit
suitable alternatives;
sends referral
to CSOs; discusses CSOs Child Protection takes child
to unit
Placement child’s needs
Unit
Issues in
residential
Issues not resolved = new placement for child unit
Source: Victorian Ombudsman (incorporating information from Department of Health and Human Services and Community
Service Organisations)
100. After children are placed in residential care, Community Services Organisations
Child Protection workers remain involved
101. The Department registers and funds CSOs
with the children:
to provide residential care to children.
• The Children, Youth and Families
102. The CSOs in this report are all not-for-
Act requires the Secretary of the
profit community organisations. When this
Department to ensure a case plan is
report was produced, there were 34 CSOs
prepared for the child and reviewed at
providing residential care in 175 residential
least once a year (sections 166-169).
care units around the State.
• Child Protection workers act as the
children’s case managers, unless the 103. Some CSOs are incorporated Aboriginal
Department appoints a CSO instead. organisations that are controlled, operated
and governed by Aboriginal people for the
• Where a CSO is the case manager,
purpose of delivering culturally appropriate
Child Protection monitors the CSO’s
services to the local Aboriginal community.
service delivery and takes responsibility
They are known as Aboriginal Community
for tasks such as preparing reports for
Controlled Organisations (‘ACCO’).
the Children’s Court.
104. CSOs take the lead role in supporting • between six and 30 per cent engage in
children in residential care. They are suicidal behaviour
responsible for children’s day-to-day care. • up to 48 per cent demonstrate
105. Where the Department appoints a CSO to problem sexual behaviour
act as a child’s case manager as well, the • between 10 and 44 per cent are
CSO undertakes extra functions including: involved in youth offending.
• working with the child and family to 110. In 2016, the Victorian Government
achieve case plan goals budgeted an additional $35.9 million over
• supporting the placement two years to support CSOs to care for
these children. The Department’s 2016
• preparing reports and making referrals Roadmap For Reform stated it would
for support. ‘begin to transform … the current model
106. The Department funds CSOs based on to a clinical treatment model’. While most
‘targets’ – being the number of children residential care units remain a ‘standard’
they can accommodate in their units model, every child is now funded at the
(usually four children per unit), regardless level for children:
of how many children actually live in the who display a significant level of complex
unit. behaviour, have multiple and complex
needs and engage in high-risk behaviours
(Residential Care Program Requirements).
Children in residential care
107. In 2019-20, the daily average number 111. The Wungurilwil Gapgapduir agreement
of children in residential care in Victoria states that Aboriginal children are
on any single day was 433. A total of significantly over-represented in residential
925 children spent time in residential care and other types of out-of-home
care throughout that year. Most of these care – at nearly 16 times the rate for non-
children were adolescents; and only 41 Aboriginal children. The rate of Aboriginal
children were under the age of 12. child removal in Victoria now exceeds rates
of removal during the Stolen Generation
108. Children in residential care tend to have period. Australian Census figures show that
complex needs. The Department’s website in 2016 only 0.8 per cent of the Victorian
acknowledges they: population was Aboriginal. As at 30 June
are often those who have experienced 2020, 21.4 per cent of children in residential
the greatest level of trauma and who, care were Aboriginal.
therefore, require the most expert
therapeutic care and support. 112. There are limited specialist residential care
options for Aboriginal children. As at 30
109. This is supported by McLean’s 2018 June 2020, only 2.3 per cent of residential
research in Therapeutic residential care: an care units (one of the 138 standard units
update on current issues which estimated and three of the 37 therapeutic units) were
that in Australia: managed by an ACCO.
• between 21 and 40 per cent of children
in residential care use alcohol and
other drugs
• between two and 36 per cent have
autism and other developmental
disorders
• between three and 23 per cent
experience depression

Figure 2: Percentage of Aboriginal children in residential care, compared with Aboriginal-managed
residential care available (as at 30 June 2020)
100%
80%
60%
40%
20%
0%
Children in residential care Standard units Therapeutic units
Aboriginal Non-Aboriginal
Source: Victorian Ombudsman (incorporating information from Department of Health and Human Services)
Previous reports on residential care 116. CCYP made nine recommendations for
systemic improvements to prevent sexual
113. Many reports have criticised Victoria’s
abuse and sexual exploitation of children
residential care system.
and young people in residential care.
114. In 2014, a Victorian Auditor-General’s
117. In 2016, an Institute of Child Protection
Office report, Residential Care Services
Studies report, Safe and sound: exploring
for Children, found profound disparities
the safety of young people in residential
in the safety, well-being and basic living
care, identified problems with lack of
conditions of children in residential care
stability in residential care placements.
when compared with children in home-
based settings. 118. The Department’s data shows that in
2018-19, children had an average of
115. In 2015, CCYP’s report “...as a good parent
2.4 residential care or Secure Welfare
would…”, found:
placements. In 2019-20, the average
an alarming level of sexual abuse and number of such placements was 2.3.
sexual exploitation was occurring in
Victoria's residential care services, and 119. One child in out-of-home care in 2018-19
the system was taking inconsistent had 45 placements, two others had 36 and
approaches to prevent these issues. 29 respectively. In 2019-20, three children
experienced 21, 22 and 25 placements
respectively.
120. CCYP’s 2019 report, In our own words, 125. Figure 3 (below) shows the State’s out-of-
Systemic inquiry into the lived experience of home care placement by type over the last
children and young people in the Victorian four years.
out-of-home care system (‘In our own
words’) found: 126. In the last four years, the per cent of
children living in out-of-home care
a pressured, poorly resourced system in residential care units each day has
[that] repeatedly failed to take the views remained around four per cent, dropping
of children and young people into account
when deciding where they should live, what
slightly every year.
they needed from their Child Protection
127. Department documents show it is seeking
workers and carers, what was happening to
them in care, and the contact they had with to ‘reduce the number of children in [out-
friends, family and community. of-home care] who live in residential care’.
121. Children and young people told CCYP: 128. Since 2016, the Department has funded
CSOs to recruit and support more foster
they often felt unsafe in a residential care
carers. However, data suggests these
system that exposed them to violence,
drug use and other criminal activity. initiatives may have been unsuccessful.
At interview, a Child Protection manager
122. In 2020, Smales et al found serious flaws reported Victoria had only been able to
in the management and delivery of health recruit 33 foster carers in the last year. The
services for children in out-of-home Department said that ‘the figure cannot
care as detailed in Surviving not thriving: be verified … we do not track state wide
experiences of health among young people recruitment’. Figure 3 (below) shows the
with a lived experience in out-of-home care. proportion of children in foster care has
These health researchers said children: reduced every year for the last four years.
felt their health needs were not adequately 129. In response to a draft version of this report,
met in care, nor did they feel listened to, Berry Street referred the investigation to
understood, or educated about health-
related matters.
a 2019 research paper by SVA Consulting,
The economic case for early intervention
123. Smales et al recommended children’s in the child protection and out-of-home
insights be used to guide meaningful and care system in Victoria. That report found
holistic change. demand for out-of-home care is increasing
by about 10 per cent each year in Victoria.
124. Residential care is already the
Department’s least favoured option for
children who cannot live at home.
Figure 3: Out-of-home care placements from 2016 to 2020 (State daily average)
Year Foster Kinship Permanent Residential Totals
2019-20 1,660 7,126 2,963 433 12,182
2018-19 1,697 6,399 2,810 453 11,363
2017-18 1,673 5,581 2,625 424 10,305
2016-17 1,560 5,043 2,407 424 9,446

Note: Columns do not always add up to the total due to a small number of other placement types

Standards for residential care 135. To help the Department and CSOs
determine whether a decision or action
130. The Department and CSOs are bound is in a child’s best interests, the Children,
by laws and standards designed to keep Youth and Families Act lists factors that
children safe and well in care. They include: must be considered. They include the need
to protect the child from harm and the
• the Children, Youth and Families Act child’s views and wishes (section 10).
• the Department’s Human Services
Standards, a set of quality standards Human rights
for Department-funded service
136. The ‘best interests’ obligation is aligned
providers such as CSOs
with Victorian human rights legislation.
• the Department’s Child Protection
Manual, a guide that covers the full 137. The Charter of Rights Act states:
range of child protection services
every child has the right, without
• the Department’s Residential Care discrimination, to such protection as is
Program Requirements, a document in his or her best interests and is needed
by him or her by reason of being a child
setting out specific requirements for
(section 17(2)).
children in residential care
• other topic-specific policies and guides. 138. It is unlawful for a ‘public authority’, such
as the Department or the CSOs:
131. The following section describes the main
to act in a way that is incompatible with
standards relevant to the alleged assaults
a human right or, in making a decision,
mentioned in this report. to fail to give proper consideration to a
relevant human right (section 38(1)).
The ‘best interests’ principle
139. Rights contained in the Charter of Rights
132. The Department and CSOs have an Act, however, are not absolute and may
overarching obligation to give effect to the be limited in certain circumstances. For a
‘best interests’ of the child. limitation to be reasonable (and therefore
133. The Children, Youth and Families Act states not unlawful) it must be ‘demonstrably
‘the best interests of the child must always justified in a free and democratic society
be paramount’ (section 10). It requires the based on human dignity, equality and
Department and CSOs to have regard to freedom’ (section 7(2)).
this principle when making decisions or 140. The Department has also published a
taking action under the Act (section 9). list of what children can expect while in
134. These laws are consistent with Australia’s residential care, including the right:
international obligations. The main • to be safe and feel safe …
international treaty on the rights of
children, the United Nations Convention • to have a say and be heard …
on the Rights of the Child (ratified by • to tell someone if I am unhappy …
Australia in 1990), states: • to have a worker who is there for me …
In all actions concerning children, • [to have] careful thought to be given
whether undertaken by public or private to where I will live so I will have a home
social welfare institutions, courts of law,
that feels like a home.
administrative authorities or legislative
bodies, the best interests of the child shall
be a primary consideration (article 3(1)).
Specific standards Care and supervision
Placement decisions 145. The Department’s Residential Care
Program Requirements state the CSO
141. When placing a child in care, the Children,
providing care to a child ‘manages, actions
Youth and Families Act requires the
and reviews day-to-day care arrangements
Secretary of the Department to provide
for children’. They set out CSOs’
for the ‘physical, intellectual, emotional
responsibilities including:
and spiritual development of the child in
the same way a good parent would’. The • care planning for the child, based on
Secretary must also have regard to the the child’s individual needs
‘treatment needs’ of a child (section 174).
• establishing and leading a Care Team
142. The Department’s Placement Framework that includes the child’s case manager,
sets out 10 ‘placement planning principles’ the supervisor in the residential care
for the Placement Unit to consider. They unit where the child is living, other key
include: residential care workers and the child’s
parents
• Placement planning should focus on
• using the Department’s Looking
appropriately matching the child to a
After Children (‘LAC’) framework
placement which is able to meet their
and processes, for managing the
individual needs.
day-to-day care of the child ‘using a
• Placement must be considerate of the collaborative Care Team approach’.
child’s history of abuse and trauma
and promote a healing environment Incident reporting and response
which is considerate of their individual
treatment needs. 146. The Department requires CSOs to report
allegations of physical and sexual assaults
• Children will reside in a safe involving children in residential care, as
environment, free of abuse and neglect. well as other incidents such as medical
143. The Placement Framework also lists incidents and children going missing in
‘placement matching factors’ to be care.
considered when negotiating placements 147. The incident reporting requirements
with CSOs. They include the age and are intended to help agencies respond
gender of other children in the house; the to adverse events and ensure affected
child’s abuse history; and the views and children and staff are safe and supported.
wishes of the child. They also give agencies the opportunity
144. The Framework also states: to learn from incidents so they can reduce
risks in future.
the placement of one child should not
jeopardise the safety or individual needs
of another child (Principle 4.2).

148. Before 2018, the Department set out 152. The Child Protection and Police Protocol
its requirements in two documents: deals with cases where children go missing
‘Responding to allegations of physical or while in residential care. The Protocol
sexual assault’ and ‘Incident Reporting states Child Protection and CSOs should
Instruction’. They required CSOs to: conduct risk assessments where children
go missing from residential care units.
• report alleged physical and sexual CSOs are responsible for making missing
assault of children to Police person reports to Police.
• notify children’s families
153. The Department monitors and oversees
• consider referring children to specialist CSOs’ incident reporting to ensure they
counselling and support services in the follow the policy and procedures. It also
case of alleged sexual assaults, with provides all ‘major’ incident reports to
the child’s consent. CCYP. CCYP may request follow-up
149. This system was criticised by some, information about the incident or the
including by the Ombudsman. In 2018, the response and may establish an inquiry
Department replaced it with a new system where it identifies a persistent or recurring
called the ‘Client Incident Management systemic issue through these incident
System’ (Incident reporting system). reports.
150. The Department’s Incident reporting

system guide requires CSOs to:
• Report all incidents that result in harm

to the child to Child Protection. These
reports are known as incident reports.
• Report all incidents that may be a
crime, such as assaults, to Police. The
guide says ‘Police should be assisted in
conducting their investigation’.
• Facilitate access to specialist victim
support services.
• Notify the child’s next of kin/legal
guardian, if the child consents.
151. During the period investigated all major

incident reports were to be submitted
within 24 hours; non-major incident reports
were to be submitted monthly.
The children’s experiences
154. The five complaints to the Ombudsman raised questions about whether Child Protection and
CSOs met their obligations to children in care. This section describes the experiences of the five
children, and Child Protection and CSOs’ handling of their care.
Quinn
Quinn spent three years in residential care from 2008 to 2011, when she was a teenager. In
2019, she contacted the Ombudsman to say she had been assaulted by an older boy in her
residential care unit and had not received a proper response.
Quinn had been diagnosed with various disabilities at the time, including an autism spectrum
disorder. She was transitioning from male to female identity. The evidence shows:
• Child Protection placed Quinn in a CAFS unit with an older teenage boy with a known
history of violent outbursts.
• There were many recorded incidents of threatened or actual violence between the pair.
• Child Protection knew about the incidents. It did not move either child until almost
two years later, after the boy repeatedly punched Quinn to the face and head and was
charged by Police.
• Quinn later disclosed the boy ‘constantly’ sexually assaulted her by grabbing her genitals.
CAFS did not investigate the allegations nor notify Police – so the allegations remain
unproven. CAFS also failed to refer Quinn for counselling.
• Quinn may have been medicated to try to control her behaviour.
• Quinn was not allowed to have female clothes or items at the CAFS unit. Later, her sexual
identity and behaviours were apparently deemed a risk to others.
Figure 4: Quinn’s timeline of key events
CAFS Foster Care x 2 CAFS residential

Disability Services Quinn, 17 years
care unit Case management
becomes involved - Co-resident old, leaves care to
Quinn 5 years old contracted to CAFS leaves CAFS Lead Tenant home
Only child in foster

care home
1999 2005 2018 2006 2008 2009 2010 2019 2011
2008 to 2011
28 violent/physical assault
incidents at CAFS - 13
between child and co-resident
Report to Child Children’s Court makes Disclosure of sexual abuse

Protection - Protection Order (not investigated)
Quinn 11 years
old and in need Co-resident physically
of protection assaulted client (Court
found proven)
the children’s experiences 29

155. Quinn is a transgender woman in her Why Quinn was in residential care
20s. She spent three years in residential
161. Child Protection became involved with
care from 2008 to 2011, when she was a
Quinn and her family when Quinn was 11
teenager.
years old.
156. In February 2019, Quinn complained to
162. Psychologists diagnosed Quinn with an
the Ombudsman that she was assaulted
‘intellectual disability and autism’ when
by another child in her residential care
she was four. She went to school with help
unit, with ‘physical and sexual harassment
from aides and received State-funded
almost from the day I moved in’. She
disability support. But when Quinn turned
also said she had been medicated to try
10, an education Department psychologist
to control her behaviour, and her carers
re-tested her and found her IQ was within
discriminated against her by failing to
‘the average range’. She was no longer
support her trans identity.
eligible for disability support.
157. Quinn wrote to the government about her
163. The following year, Child Protection got
experiences in May 2018. The Department
a report raising concerns about Quinn’s
responded four months later but did not
welfare. Quinn’s mother admitted to
acknowledge her allegations of assault or
Child Protection she was having difficulty
offer to investigate.
coping, in part because Quinn was
158. Quinn lived in one unit, which was displaying aggressive behaviours. There
managed by CAFS during her years in was evidence that Quinn’s parents were
residential care. To understand Quinn’s using physical force against her.
experience, the investigation:
164. Child Protection tried to work with Quinn’s
• examined her Child Protection and family and reconnected them with State
CAFS files disability support. However, after a few
months, Quinn went into foster care to
• obtained written responses from the
protect her from harm. She has had limited
Department, CAFS and Police
contact with her family since.
• interviewed Quinn and three
Department representatives. 165. By the time Quinn was 14, her foster carers
could no longer care for her. A Child
159. The investigation did not interview Protection Practitioner wrote on Quinn’s
staff from CAFS because the complaint file that any new placement needed to
involving CAFS was historical and CAFS provide ‘a safe and supportive environment
no longer employs the staff with direct for [her] to live’.
knowledge of Quinn’s care.
160. The evidence confirmed there were many

alleged assaults involving Quinn while
she was in care. It raised questions about
Child Protection’s decision to place her in
the CAFS unit, and Child Protection’s and
CAFS’ responses when problems emerged.
CAFS placement Physical assaults
Placement risks 171. Almost immediately, there were problems.
Incident reports show that within days,
166. In mid-2008, Child Protection placed
CAFS workers saw the older boy abuse
Quinn in a CAFS standard four-bed
Quinn verbally. A few days later, he
residential care unit.
allegedly physically assaulted her. During
167. At the time, there were two other children Quinn’s first five months in the unit, there
with disabilities in the unit. were 10 recorded incidents involving
threatened or actual violence between
168. Child Protection records show one of the the pair. Some of these involved knives,
children, an older boy, had aggressive forks and other weapons. Records show
behaviours associated with his disability. only one of the incidents was reported to
The records refer to ‘aggression, Police.
troublesome behaviour and … violent
outbursts’. One record said he had ‘rages 172. Over the following 14 months, there were
that last 4-6 hours at a time’ and at least other incidents. Some involved fights
two staff were required to control him. The between children in the unit, including
record also said kicking and swearing were Quinn. Others involved alleged assaults by
common. the children on CAFS workers in the unit.
Quinn’s behaviour reportedly also became
169. There is no evidence to show how Child more aggressive.
Protection and CAFS intended to manage
the boy’s behaviours to ensure Quinn was
safe and supported.
170. Quinn’s records also noted she would need

to adjust to living with other young people
who could, at times, be a ‘major source of
irritation to [her]’ (see Figure 5).
Figure 5: Records from Quinn’s file
Quinn Quinn
Source: Department of Health and Human Services

173. Records show Child Protection knew about 175. Child Protection records show it planned
these problems soon after it placed Quinn to move the older boy in mid-2009, just
in the unit in mid-2008. Child Protection over a year after Quinn moved to the unit.
reviews incident reports as part of its The records state ‘violent and threatening
normal processes. A manager made the behaviours at the resi unit have caused him
following notes on the reports: to face criminal charges’. This referred to
charges arising from alleged assaults by
the boy on CAFS workers.
Notes on an incident report from July
2008: 176. In early 2010, Police charged the older boy
I’d like information about how long [Quinn with unlawful assault on Quinn. Records
and the older boy] have been here, their say he asked Quinn to move and she
daytime activities, case direction and family refused, and he ‘rushed’ her and punched
involvement. Then we will meet with CAFS. her repeatedly in the head and face. The
charge was found proven at court.
Notes on an incident report from August
2008: 177. No records were provided to the
Does [Quinn] have a diagnosed Autism investigation to show what follow-up
Spectrum Disorder? If so, staff need training support and care was provided to Quinn.
/education regarding communication. What
led up to this incident? 178. When Child Protection reported to the
Children’s Court on Quinn’s placement two
Notes on an incident report from months later, it did not mention the assault.
September 2008:
The report said:
Extra support (staff + counselling) already
in place. No action – Systemic – I see we are [Quinn] has the right to safe and stable
discussing this residence soon. accommodation, which is met through
[her] placement through [CAFS].
179. The report also said Quinn ‘likes living in

Source: Department of Health and Human Services [her] current placement’.
180. By contrast, Quinn told the investigation

‘I never felt safe there, not for a second’.
174. Records show Quinn and the other resident
asked to be separated. The month after 181. Child Protection did not move the older
Quinn moved into the unit, the other boy from the unit until mid-2010, four
resident asked to leave because he could months after his unlawful assault on Quinn
not ‘get along’ with her. At interview, Quinn and two years after Quinn moved into the
said: unit.
Me and [the older boy] said [we wanted 182. Quinn’s file records her reaction to the boy’s
to be moved] so many times. I would
departure as ‘extreme relief’ (see Figure 6
say it and he would say it. He’s like ‘you
should move because I was here first’. I on next page).
was like ‘I’ve always been a good person,
the only reason I’m playing up is because
he was antagonising me. He plays up all
the time. He should be the one to leave’. I
didn’t care where I was moved to, I never
mentioned a specific place, it was just like
as long as it’s not here.
Figure 6: Record from Quinn’s file
Quinn
Quinn
Alleged sexual assaults 187. In a written response to the investigation,

CAFS said it may have wrongly
183. In 2011, almost a year after the older boy’s
categorised the incident as ‘Category 2’
departure, Quinn told a CAFS worker that
because:
the boy sexually assaulted her ‘constantly’
while they were in the same unit. CAFS’ the [other boy] had moved out twelve
incident report said: months earlier, therefore the events were not
recent and were not likely to occur again.
[Quinn] became quite angry during the
afternoon, yelling and swearing. Staff [name 188. CAFS acknowledged it failed to offer
removed] met with [Quinn], who said counselling and report the allegations to
[she] is going to sue [DHHS] and CAFS as
Police.
they did not protect [her] against being
sexually abused by [an older boy who used 189. CAFS told the investigation this was the
to live in the unit, name removed]. [Quinn]
disclosed to staff that [the older boy] used
only time Quinn reported the alleged
to constantly grab [Quinn’s] genital area. sexual assaults. CAFS referred to Quinn,
who at the time was nearly 18 and was
184. According to the case worker’s notes, about to move out of the unit, as being
Quinn said she had reported the alleged ‘extremely anxious’ about moving on. It
assaults before: said she ‘becomes very obsessed about
[Quinn] stated it was reported to staff
particular issues and plays them over and
and nothing was done. [Quinn] stated over’ due to her disability.
it had occurred about 100 times over
a period of time. [Quinn] thinks it was 190. The Department told the investigation
reported to the case manager at the time. that when it reviewed the incident report,
it changed the incident to a ‘Category 1’
185. CAFS’ incident report incorrectly and addressed this with CAFS. Its records
categorised the incident as a less serious said Child Protection would conduct a
‘Category 2’ level assault. ‘Quality of Care’ review, but no such review
took place. In a written response to the
186. The incident report stated that Quinn’s
investigation, the Department explained
‘concerns have been acknowledged and
the incident did not meet the criteria for
[she] knows that they will be followed up/
this type of review because it was a ‘client
passed on’. However, CAFS advised the
to client’ incident.
Ombudsman it did not take any action.
The incident report recorded that sexual
assault counselling was ‘not required’, and
Police were not contacted. There is no
record that CAFS advised Quinn’s mother,
who was still her legal guardian.

191. The Department said it had planned to 196. Quinn said she complained about being
report the allegations to Police, interview medicated at the time. She said two CAFS
Quinn and consult disability specialists. workers also opposed her medication, but
But in February 2020, the Department it happened anyway. She said, ‘I was on so
advised the investigation it could find no much medication, I was that slow, it’d take
records that its staff or CAFS had taken me two minutes just to answer a question’.
that action. Police told the investigation it
had never received a report about Quinn’s 197. Registered disability providers must obtain
sexual assault allegations. The allegations the Department’s authorisation before
therefore remain unproven. using a ‘chemical restraint’, as it is termed
in the disability sector (Disability Act
2006 (Vic)). There appear to be no such
Other concerns
protections for children in residential care.
192. When the investigation looked at Quinn’s
records, it identified other concerns about 198. There is no record that Child Protection
her care. or CAFS asked Quinn’s doctors if the
medication was used as a chemical restraint,
Health, medication and possible chemical and it is not known if this was the case.
restraint 199. The current Royal Commission into
193. Quinn’s records show Child Protection and Violence, Abuse, Neglect and Exploitation
CAFS did not organise regular counselling of People with a Disability is examining
for her, despite her history and experiences the use of medication being used as a
in the unit. Quinn’s records of counselling chemical restraint in the disability sector.
contain a gap of more than two years.
LGBTIQ discrimination
194. Quinn’s records show she was prescribed
psychotropic drugs at various times. A 200. There is also evidence supporting Quinn’s
letter from Quinn’s paediatrician indicates complaint that CAFS did not support her
the drugs were used to treat behaviours when she started identifying as a girl.
associated with her autism spectrum
201. The Children, Youth and Families Act
disorder.
recognises the importance of children’s
195. At interview, Quinn said she thought she gender and sexual identity to their best
was given the medication to control her interests. The Act states that when
behaviour: determining what decision to make or
action to take in the best interests of the
They told me it was to stop me being child, consideration must be given to
anxious, they said my behaviour was out
the child’s ‘social, individual and cultural
of control. I wasn’t out of control for the
sake of being out of control. identity’ as well as the child’s ‘sex and
sexual identity’ (section 10).
[The older boy] was actually out of
control. I was provoked, I was terrorised, 202. However, the investigation did not identify
of course I’m going to react aggressive. policies or procedures setting out the
But they saw it as bad behaviour, so
Department’s and CSOs’ practical obligations
according to their stupid logic, it was bad
behaviour for me to defend myself. to LGBTIQ children either then, or now.
203. In 2008 when Quinn moved into the

unit, CAFS was aware Quinn liked to
dress in girl’s clothing. CAFS managed
Quinn’s earlier foster care placement, and
Quinn’s foster carers told CAFS about her
preference for girl’s clothing.
204. At interview, Quinn described the actions 208. The investigation did not identify any
of CAFS workers in the unit: incidents to support the workers’ concerns.
In the beginning, from the moment I got 209. A Department representative said at
in, in 2008, they were already thinking of interview it was not Department policy at
taking everything I had.
the time to refuse children their choice of
About a year or two later, they [CAFS] took clothing and other items or practices.
everything off me. Everything female. The
dresses, clothes, and even a doll. I remember
Where is Quinn now?
[the case manager] telling me they wanted
to take it away straight away, but it was 210. Quinn left residential care in 2011. At
a grey area. Gays had anti-discrimination first, she moved to a different type of
[protections], but transgenders did not have
supported placement where she could
any discrimination [protections] at the time.
They debated if we stop this kid identifying prepare to leave State care. She now lives
as trans, they didn’t use the word ‘trans’ independently.
back then, I think they said ‘cross dresser’,
are we technically breaking the law of gay 211. Quinn told the investigation she has
discrimination? Then [CAFS] decided cross struggled since leaving care, with unstable
dressing was not the same thing as gay, housing and lack of job opportunities. She
so we can take them all off him. [The case said she was recently remanded in custody
manager] disagreed with it being taken away.
after getting into a fight with people who
205. Quinn said she was not allowed to have were threatening her. She said she has not
the hormonal medication she wanted to joined the National Disability Insurance
support her transition, even though she Scheme due to concerns about having to
was medicated for other reasons. She said: undergo more assessments and her bad
experiences with services.
It was weird because I wanted to get on
hormones and [CAFS] said no. I ended 212. Quinn told the investigation her
up getting put on more medication, they experiences in residential care destroyed
were saying I was out of control and a
her life and have at times left her suicidal.
really bad kid.
206. Quinn said CAFS staff members told her CAFS’ response
‘we’re just doing it to protect you’, but she
213. In its response to a draft of this report in
felt ‘nothing was done to protect me’. She
May 2020, CAFS’ Chief Executive Officer
said:
said:
I wanted to be taken out of that house or
CAFS is sorry for the trauma experienced
have him [the older boy] taken out. Some
by [Quinn], and wishes to assure [the
of it was because of the molestation, but
Ombudsman] that our knowledge and
some was because of the discrimination
experience in relation to the issues raised
against me for being trans.
by [Quinn] has expanded since she was in
our care, and what we know now is very
207. Some CAFS records confirm Quinn’s
different to what we knew then.
account. They show staff were concerned
after two younger girls moved into the 214. The Chief Executive Officer detailed
unit in mid-2010. A document prepared by improvements to services and processes
Quinn’s case manager said: since Quinn’s time in care. Appendix 1
since the arrival of young girls at the house,
contains a full copy of CAFS’ response.
much of this activity [such as Quinn’s sexual
behaviour and preference for women’s
clothing] has been banned as workers were
wary of his fascination with younger girls.

Kylie
Kylie is a young Aboriginal woman who has been in residential care since 2018, when she was
14 years old. Her mother contacted the Ombudsman with concerns about Kylie’s care. She
said Kylie had been raped while away from her residential care unit and she feared for her
daughter’s safety.
The investigation found that since going into residential care, Kylie has lived in three different
units managed by Uniting, Berry Street and VACCA. The evidence shows:
• Kylie began using drugs after going into residential care and started leaving her unit and
meeting older men.
• Around seven weeks after going into residential care, Kylie told workers she had been
raped by an adult man in a laneway. Police are continuing to investigate this allegation.
• Other children in the units also allegedly assaulted Kylie.
• Berry Street and VACCA said Child Protection pressured them to take Kylie, even though
there were risks involved in placing her in their units.
• Child Protection is meant to give Aboriginal children a cultural plan to support their
connection to their heritage and culture within 16 weeks of going into care. It did not give
Kylie her plan for more than one year - approx 53 weeks.
Figure 7: Kylie’s timeline of key events
Shared care
VACCA
therapeutic
residential care
VACCA unit & home
therapeutic
Uniting residential Kylie moves into
Secure Secure new Community
residential Berry Return Berry care unit
Welfare Welfare Service
care unit Street Street
Organisation
residential residential Return residential care unit
care unit care unit home
2018 2019 2020
Absconding,
misuse of drugs,
sexual exploitation Absconding
Report to Children’s Alleged Alleged physical Alleged Alleged

Child Court rape in assault by physical physical
Protection makes the co-resident assault in the assaults by
– Kylie 14 Protection community community co-resident
years old Order
in need of
protection
215. Kylie is a young Aboriginal woman in 221. Kylie’s mother told Child Protection she
her teens. She has been in and out of could not manage Kylie’s behaviour. Child
residential care since mid-2018. Protection records describe Kylie as having
‘behavioural disturbance and anxiety’. The
216. In July 2018, Kylie’s mother contacted the records described incidents during which
Ombudsman with concerns that Kylie had Kylie ‘bang[ed] her head on walls’ and
started taking drugs and was running away threatened self-harm with a knife.
and meeting up with older men. Shortly
afterwards, she said Kylie had been raped 222. Child Protection attempted to support
while away from her residential care unit. the family. However, it soon removed Kylie
She said she feared for her daughter’s from the home.
safety.
223. Child Protection could not find family
217. The investigation found Kylie has moved or friends to care for Kylie. In mid-2018,
many times since going into residential it applied to the Children’s Court for a
care. She has lived in three different Protection Order and placed Kylie in
residential care units, managed by Uniting, residential care. She was 14 years old at the
Berry Street and VACCA. The Department time.
has also attempted to return her home on
some occasions. Uniting placement
218. To understand Kylie’s experience, the Placement risks
investigation: 224. Child Protection placed Kylie in a Uniting
• examined records from Kylie’s Child standard four-bed unit with three girls of
Protection, Uniting, Berry Street and similar age.
VACCA files 225. Child Protection initially placed Kylie in
• obtained written responses from the the unit on an emergency basis, and her
Department, Uniting, Berry Street, Placement Referral document lacked
VACCA and Police detail. Child Protection did not update it,
• interviewed Uniting, Berry Street and despite a request from Uniting. In response
VACCA representatives and three to a draft of this report, Kylie’s mother
Department representatives. stated she provided detailed information
to Child Protection about Kylie to support
219. The investigation confirmed multiple her placement.
alleged assaults against Kylie after she
went into residential care. It looked at 226. At interview, a Uniting representative
whether the Department and CSOs recalled conversations about whether
were aware of these risks and how they Kylie was a suitable match with the other
responded. children. The representative said there
were three girls in the unit, two who were
settled and the third, like Kylie, was new to
Why Kylie was in residential care
residential care. Uniting did not document
220. Child Protection has been involved with these assessments.
Kylie’s family for many years due to family
violence, drug use and mental health
issues. By May 2018, Kylie’s mother and
siblings had relocated and were living with
friends. There were more reports of family
violence in that house.

227. Problems soon emerged. Records show [T]here is a lack of clarity of the
that four days into Kylie’s placement, a responsibilities of the residential service
program, primarily in regard to supporting
worker ‘smelled substances’ from one of
the cultural needs of young people in
the girl’s bedrooms. The next day, one of residential care, arranging, facilitating
the girls said ‘she gave [Kylie] her first and recording Care Team meetings and
bong and … she coughed her guts up’. case planning actions, such as health
A week later, a worker again noticed a assessments, education etc.
smell of cannabis. Records say a worker
233. Records show Child Protection gave
reinforced a ‘zero tolerance’ approach
Uniting a ‘Crisis Management Plan’
to illegal drugs. However, that evening a
for Kylie. However, it was a template
worker found Kylie and one of the other
document with no reference to Kylie’s
girls with bowls of cannabis. Seven weeks
individual needs. Uniting asked Child
after moving to the unit, Kylie told a
Protection to update it, but it did not. The
worker a local drug dealer was giving her
Uniting representative said at interview
ice.
this was the role of the child’s case
228. Kylie’s mother told the investigation neither manager (which, in Kylie’s case, was Child
Uniting nor Child Protection informed her Protection), with Uniting’s input.
about Kylie’s suspected drug use.
234. Uniting told the investigation:
229. Kylie also started running away at night staff made active attempts to locate
and was reportedly meeting up with adult [Kylie] each time she absconded … [but]
men. staff are unable to physically prevent any
young person from leaving the house.
230. Child Protection records show an adult
man was believed to be buying alcohol Alleged assaults
for the girls in the unit. Child Protection
noted the man had made ‘full admissions 235. Around seven weeks after Kylie went
to Police in 2002 regarding the sexual into residential care, it is reported that
penetration of a child’ but the charges she told a worker an adult man raped
were struck out in court. Then in 2017, the her in a laneway. Kylie’s mother told the
man was arrested for an alleged sexual investigation, her daughter said she was
assault of a person with a disability. Those given the drug ‘ice’ by this man.
charges had not proceeded.
236. Police are continuing to investigate this
231. Child Protection and CSOs are meant to allegation.
use Care Teams and Crisis Management
237. Child Protection records reported Kylie had
Plans to manage the sorts of risks that
gone missing from the unit at the time of
arose in Kylie’s case.
the alleged rape and a Uniting worker was
232. There is no record of Uniting establishing out looking for her.
a Care Team for Kylie. Uniting provided
238. Uniting submitted an incident report to
conflicting information about who was
Child Protection and notified Police.
responsible. At interview, the Uniting
representative said CSOs are meant to 239. Police told the investigation the Uniting
establish and lead Care Teams. However, worker did not respond to its requests
Uniting’s written response to the for a statement for several weeks. When
investigation said: the investigation raised this issue with the
Department, it said it expects CSO workers
to cooperate in a full and timely manner. A
senior Uniting manager agreed.
240. On the same day as the alleged rape, 246. Child Protection initially refused. A
one of the girls in the unit told a Uniting Placement Unit manager responded to
worker she had ‘bashed’ Kylie. Police told Uniting’s email:
the investigation it had no record of this
[A]s a Care Team we will need to discuss
assault. Records show Uniting informed how we can best manage the current
Child Protection, but there was no incident situation between the two girls as there
report. is no capacity in the residential space to
move either girl to a safe placement.
241. There are also records of three earlier
incidents involving another girl in the unit. 247. Later that day, however, Child Protection
Kylie reported one of the other girls: decided to move Kylie to Secure Welfare
‘due to significant risk issues’.
• ‘Felt her up’ when they were sitting on
the couch watching TV. Kylie said the 248. Uniting told the investigation it wanted
other girl touched her leg and put her Kylie to stay in the unit. It said it asked
head on her shoulder. Child Protection not to put her in Secure
Welfare because she needed to be with
• Touched her breast.
trusted carers while she recovered from
• Touched her vagina. the alleged assaults.
242. Uniting reported the first incident to 249. The Uniting representative raised concerns
Police, but Kylie did not want to make at interview about Child Protection’s
a statement. Child Protection records handling of the move. Records say Kylie
say Police interviewed the girl regarding had told Uniting workers that morning that
the third matter, but she denied Kylie’s she wanted ‘to provide evidence to have
allegation. this man charged’. Kylie’s mother told the
investigation Uniting instructed her to tell
243. Uniting told Child Protection about the
Kylie she would be moved, just before she
incidents but did not lodge incident
was due to go to hospital for a forensic
reports. There is no record of Child
medical examination for the alleged rape.
Protection following up the provision of
incident reports. 250. Kylie reportedly fled before the examination
could be conducted. Her mother told the
244. Records show Kylie’s mother also told
investigation she was fearful about the
Child Protection that one of the girls
invasive tests.
in the unit had made sexual advances
towards Kylie. At interview, the Uniting 251. Police told the investigation Kylie made a
representative said Uniting was not aware statement about the alleged rape about a
of this report. year later.
Placement termination 252. Kylie stayed in Secure Welfare for 11 days

while Child Protection looked for a new
245. At interview, the Uniting representative placement.
said after Uniting heard about Kylie’s
alleged bashing, it asked Child Protection
to move the other girl. In an email, it
told Child Protection and the Placement
Unit that Kylie was ‘presenting genuinely
frightened of [the other girl]’ and was
‘scared to return’ to the unit while she was
there.

Berry Street placement 256. Berry Street said it followed its ‘usual
matching process’ to check Kylie was a
Placement risks
suitable match with the other children in
253. Child Protection asked Berry Street to the unit. It provided a copy of its ‘matching
accept Kylie and she moved into one of its tool’ document, but it was blank. At
standard four-bed units. interview, a Berry Street representative
said Berry Street had done ‘dynamic
254. Child Protection gave Berry Street limited
matching’. Berry Street assessed the
details about Kylie’s experiences at Uniting.
match as ‘low risk’.
They referred to Kylie’s cannabis use, but
did not mention her absconding or a risk 257. Child Protection records show it looked
of sexual exploitation. for other options for Kylie, but without
success (see Figure 8).
255. Berry Street told the investigation
it accepted Kylie as part of a ‘swap’
organised by Child Protection. Berry Street
wanted Child Protection to move one of
the children who had been living in the
unit after a ‘major incident’. It said Child
Protection would only agree if Berry Street
agreed to take Kylie and another child.
Figure 8: Placement Unit record of efforts to secure placement

258. Shortly after agreeing to take Kylie, Berry 262. The Department said the placement had
Street agreed to accept another child. become characterised by:
Berry Street said this involved medium to
intense and volatile conflict between the
high risks for all the children. It said: [children in the unit] and other young
Berry Street also identified that there was people with whom they were associating
a high risk that [the new child] entering the in the community.
placement would cause placement disruption
for all three young people [already living in Alleged assault
the unit], however the placement proceeded
because of pressure by the DHHS. 263. When Kylie had been in the unit for
around three months, records show that
259. Kylie had been in the unit less than a her mother contacted Berry Street and
month when Berry Street told Child reported that Kylie had been physically
Protection that she had run away three assaulted by an adult man while away from
nights earlier and had not returned. When the unit. The man was a friend of one of
workers found her, they took her to Secure the other children in the unit.
Welfare for two nights. She returned to
Berry Street but continued to run away. 264. Berry Street told Child Protection the
other child asked the man to ‘bash [Kylie]
260. Records show Berry Street asked Child after an incident at the unit’. Berry Street’s
Protection if there ‘was some kind of safety incident report said Kylie refused to return
plan in place for this’. Child Protection to the unit until the next day. It said she
had given Berry Street a copy of its Crisis told workers she ‘got strangled again’ and
Management Plan for Kylie, but it had was ‘okay’.
not been updated. Berry Street’s written
response to the investigation said ‘this 265. Berry Street and Child Protection records
[plan] was not altered while [Kylie] was in contain detailed information showing they
Berry Street’s care’. reported the assault to Police (see example
at Figure 9).
261. The Department said Berry Street did not
provide daily update records for Kylie and
‘there is very little narrative about what was
occurring for [Kylie] while she was at the
unit’. In response to a draft of this report,
Berry Street said it was not required to
provide daily updates under the Residential
Care Program Requirements or its service
delivery agreements. It said it provided
regular email and telephone updates to
Child Protection on key issues.
Figure 9: Child Protection record, November 2018
Kylie
Kylie
DHHS

266. Police told the investigation they had no 272. Records show Child Protection gave
record of the report. They said they had VACCA information about Kylie’s history
dealt with the missing person’s report so it could make an informed assessment.
about Kylie and had no records about the However, the VACCA representative said at
alleged assault. interview that Child Protection repeatedly
refused access to Kylie’s Child Protection
267. At interview, the investigation asked file, which VACCA ordinarily reviews before
the Berry Street representative what accepting placements. An email from Child
else Berry Street did in response. The Protection to VACCA confirms this, saying:
representative said there were no follow-
up actions in the organisation’s records. the file review will not be possible because
They said Child Protection could have this is no longer allowed. We are able to
provide your office with relevant information.
picked this up.
273. The VACCA representative said Child
268. In response to the draft report, Berry
Protection also pressured VACCA to
Street said the characterisation of this
accept three children, including Kylie, at
incident suggests it did not actively or
the time. They said this was to ‘fill targets’
empathetically respond to Kylie. Berry
and the ‘matching was not the best’. The
Street said on the night of the alleged
representative said:
assault, workers went out to look for Kylie
twice, made repeated telephone contact • two other children in the unit were not
with Kylie and her mother and contacted ready for therapeutic care
Child Protection and Police. Berry Street
• Kylie’s behaviour, which was
noted Police should have been able to
aggressive at times, posed a risk to the
confirm report/s were made given officers’
other children
details were noted in the records. It said no
negative inferences should be drawn from • one of the children had an intellectual
the lack of Police documentation. disability and behaviours that were
too challenging for a four-bed unit run
269. Kylie reportedly retaliated against the by two workers. The representative
other resident with threats of her own. At said this child ‘needed more than the
the end of 2018, Child Protection decided mental health services we are able to
to move her back home with her mother provide. We are not a mental health
while it arranged a new placement. service.’
VACCA placement 274. When the investigation asked the

representative why VACCA agreed to
Placement decision placements it knew were unsuitable, they
270. In late 2018, Child Protection placed Kylie said VACCA risked being investigated for
in a VACCA residential care unit. It was her under-performance otherwise. They said:
third placement in six months and her first to be threatened to lose targets of a
placement with an Aboriginal Community placement is a real pressure for us … we get
Controlled Organisation. the ‘but you are underperforming on target’.
271. The unit was a therapeutic unit. Specialist

Alleged assaults
panels of Child Protection and CSO
workers assess placements for therapeutic 275. Although records show Kylie’s behaviour
units, and this is what happened in Kylie’s initially settled in the VACCA unit, she
case. again reported physical assaults by
another child in the unit.
276. In the month after Kylie moved to the unit, Discussions were held with the resident
she told a Child Protection worker and her who allegedly assaulted the young female
and his responses were clear in that he
mother that a younger boy was assaulting
showed no acknowledgement of what he
her. The Child Protection worker recorded was supposed to have done. He responded
allegations that the boy: several times with statements such as
“what are you talking about?” His inability
punched, kicked, pushed, follows [Kylie] in
to comprehend may be due to his IQ
her room and in the community and threw
(around 47) but after much discussion he
things at her. On one occasion he threw a
remained of the view that he did not know
slide board at her and caused a mark on
anything about what was being discussed.
her cheek. Staff members tried to help,
but [Kylie] did not know their names. 281. Child Protection and VACCA did not
277. Kylie reportedly complained ‘all DHHS complete an incident report or notify
does is separate families’ and asked the Police about these allegations. In response
Child Protection worker: to the draft report, VACCA maintained it
was Child Protection’s responsibility to
What’s the point of moving a child from complete the report as it had received the
a place that is regarded as not safe, but allegations.
plac[ing] that child into another place
that is also not safe? 282. VACCA also said it was unable to make
278. Kylie told the Child Protection worker she a Police statement on Kylie’s behalf and
had reported the assaults to VACCA. The ‘there was, therefore, no means by which
worker recorded that she telephoned the to make a Police report’.
unit and was told the unit manager would 283. The investigation notes there is a
have a ‘chat’ with the boy. difference between a Police statement
279. At interview, the VACCA representative that a victim of a crime may need to make
said VACCA had no record of Child to Police and a Police report of a possible
Protection’s contact about the allegations offence that anyone can make.
at the time. They said Child Protection 284. In Police’s response to the draft report
workers did not usually contact the unit dated 14 January 2020, the then-Chief
directly and communication usually Commissioner said there are multiple
occurred through the Placement Unit. The Police and departmental policies that
representative said: provide clear direction to Police and
there were certainly instances of issues agencies to ensure Police reports are made
between [Kylie and the boy] but nothing and recorded. He stated one such policy:
that constituted … assault, to my knowledge.
emphasises that all reported incidents
280. The VACCA representative said Child are to be recorded [by Police] regardless
of where the information is received first,
Protection asked VACCA to attend a
second or third hand, unless there is
meeting about the allegations in February credible evidence available at the time of
2019. VACCA later wrote to Child reporting to suggest that a crime has not
Protection setting out its response: occurred.
At no time has Child Protection contacted 285. Regarding alleged assaults in residential
VACCA to inform them of such allegations. care, Kylie told the investigation that
VACCA welcomes such communication
and is more than willing to provide
sometimes when she reports incidents,
immediate response to CP in relation to all including staff behaviour, she gets told
issues regarding our shared clients. Under ‘you’re a liar’. She thinks Child Protection
the CMS guidelines it is the responsibility of needs to do more so that care providers
CP to investigate such allegations if those ‘don’t think they can get away with this as
allegations were made directly to CP.
it’s just more trauma’.

Other concerns 291. Uniting and Berry Street did not engage
an appropriate member of the Aboriginal
286. The investigation also observed other
community for their investigations of
problems with Kylie’s care.
Kylie’s incidents.
Cultural planning and support 292. The evidence also shows Child Protection
287. The Children, Youth and Families Act did not give Kylie an endorsed cultural plan
creates specific requirements for until mid-2019, more than 53 weeks after
placement and care of Aboriginal children she entered residential care.
in residential care. This recognises 293. Uniting and Berry Street outlined steps
the trauma caused by past child they took to encourage Kylie to maintain
protection practices. It also recognises contact with her family and culture while
that connection to culture and self- Kylie was in their care. Berry Street said
determination in Aboriginal families are it held a cultural planning meeting with
strong protective factors for children. Kylie and her mother just before Kylie’s
288. Amongst other things, the Act and Child placement ended.
Protection policies say: 294. In response to the draft report, Uniting
• The Department is to consult an said its focus during Kylie’s eight-week
Aboriginal agency before deciding placement was creating stability and
to place a child in out-of-home care connection with her, which would help it
(section 12). begin the cultural plan.
• The Department and CSOs are to 295. Berry Street’s response noted Kylie’s
involve the child’s Aboriginal community cultural plan had not been progressed
in dealing with incidents and include a when she moved into its care and she was
relevant member of the community in only with Berry Street for three and a half
any investigation about abuse. months. It said Child Protection told Berry
• The Department must give every Street it would develop the plan, although
Aboriginal child a ‘cultural plan’ which it recognised Berry Street also had a role.
identifies their cultural support needs It said Berry Street has since begun a
(section 176). The plan assists the project to further strengthen its approach
child to develop and maintain their to cultural planning and connection for
heritage and encourages connection Aboriginal children in its care.
to community and culture. Care Teams 296. VACCA followed up Kylie’s cultural plan
are to prepare plans for endorsement with Child Protection after she moved
by the head of an Aboriginal into its unit. Its Aboriginal Children’s
Community Controlled Organisation Healing Team also developed a plan to
within 16 weeks. support Kylie’s connection to culture and
289. These requirements were not always met community and engage in cultural healing.
in Kylie’s case. Records show Kylie was engaging in
weekly cultural activities. At interview, the
290. Child Protection sought advice from VACCA representative said VACCA also
Lakidjeka (a specialist Aboriginal began supporting Kylie’s relationship with
consultancy service within VACCA) about her mother through ‘co-parenting’.
Kylie’s first placement with Uniting. It also
consulted Lakidjeka when she moved
to Secure Welfare. However, there is no
record of any consultation regarding her
Berry Street placement.
297. Kylie received her endorsed cultural plan in 303. In response to the draft report, Kylie’s
mid-2019. The Department acknowledges mother said she thinks residential care
it was: workers need better training. She said
some are:
not compliant with practice guidelines in
relation to the timelines for referral to the unprofessional ... [they] become
Senior Advisor Aboriginal Cultural Planning extremely emotional and attached,
and the timeframes to facilitate the … and it really affects their professional
approval of [Kylie’s] Cultural Plan. relationship with the children ... [they]
hide things from documents and
Drug services [become] real good friends with the child.
298. There is no indication Kylie used drugs 304. After discussing the draft report with the
before she went into residential care. As this investigation, Kylie said:
report noted earlier, her records show she
I am happy this investigation is being
began using cannabis days after moving made public so when kids do go into resi
into the Uniting unit. Seven weeks after they won’t have to suffer like we did.
moving into the unit, she told a worker a
local drug dealer was giving her ice. The CSOs’ responses
299. The Residential Care Program Uniting
Requirements require CSOs to have
305. Uniting’s Chief Executive Officer provided
policies on responding to alcohol and
a detailed response to the draft report
drug use. They also require CSOs to refer
which said: ‘I extend my sincere apologies
children with substance abuse issues to a
to [Kylie] and her family for her experience
drug and alcohol treatment service.
while in our care’.
300. Records contain no evidence that Uniting
306. Uniting acknowledged it did not follow
referred Kylie to a drug and alcohol
incident reporting requirements in full for
treatment service.
all of the incidents involving Kylie, but said
there was contact with Police or Child
Where is Kylie now? Protection in all cases.
301. At the end of 2019, Child Protection told
307. The Chief Executive Officer said an
the investigation that VACCA and Kylie’s
independent review of Uniting’s residential
mother were sharing Kylie’s care. Child
care model and practices had been
Protection said it was increasing Kylie’s
undertaken. They said Uniting is investing
time at home and working to reunify her
in services to ensure placements are safer
with her family full-time.
and decisions are better informed by the
302. In August 2020, Kylie’s return home broke child’s individual needs and experiences.
down and she is again living in residential This includes a new ‘Risk Management
care with a new CSO providing care. Child Tool’, stronger relationships with local
Protection is supporting Kylie to transition Child Protection teams and Aboriginal
to independent living, with cultural and organisations, and better oversight of
community supports. Kylie told the critical incidents.
investigation she had been placed into a
308. Uniting said it is developing ‘a corrective
residential care unit in Melbourne and that
action plan to address in detail each of the
Child Protection were trying to ‘force’ her
concerns raised in the report’. Appendix 1
to move into a flat with a girl she doesn’t
sets out its full response.
get on with and who takes drugs. She said
she wants to be in the country near her
family, supports and preferred school.

Berry Street 314. Berry Street also recognised that, in Kylie’s
case, it could have done better to support
309. Berry Street cared for four of the children
development of a cultural plan. It said it is
in this report. Its Chief Executive Officer
undertaking a 12-month project to increase
accepted there were areas where it could
staff capabilities in this area.
have done better to care and advocate for
the children. They said Berry Street tried 315. Appendix 1 sets out responses from
its best to deliver quality ‘care, supervision Berry Street’s Board President and Chief
and support within the ill-equipped and ill- Executive Officer.
designed residential care system’.
310. In September 2020, Berry Street told the VACCA

investigation it would make an unreserved 316. VACCA’s Chief Executive Officer welcomed
apology to the four children in this report the opportunity to respond to the draft
who had been within their care, and offer report and noted the positive comments
to meet with them and their families. about Kylie’s increased engagement when
she moved into VACCA’s care.
311. Berry Street said:
317. Appendix 1 sets out VACCA’s full response
The placement of these children
emphasises the challenges faced by CSOs to the draft report.
to act in the best interest of children
when placement referral information
is incomplete, vital information is not
provided and the placement of children is
often a resource-driven ‘negotiation’ …
In accepting the children, Berry Street

actively considered the suitability of
the children for placement, identified
risks and raised key concerns with Child
Protection. Measures were put in place to
mitigate these risks for the safety of the
children and their co-residents.
312. The Chief Executive Officer said that since

March 2019, Berry Street:
• has been ‘much firmer in saying no to

proposed placements when there are
clearly identified risks’
• is reviewing its risk assessment process
and tool and its staff capability to
make placement decisions.
313. Berry Street said it recently undertook
extensive work to support senior staff
and external investigators to manage
incident reporting. It said this has been
done without additional funding from the
Department. It also said the Department
determines if incident reports have been
correctly categorised and refers them back
to CSOs if it disagrees.
Brittany
Brittany is in her teens and has been in and out of residential care since 2018, when she was
11 years old. Her records describe concerning behaviours, including self-harm, and say she is at
risk of sexual exploitation.
In January 2019, a family friend reported to the Ombudsman that Brittany was allegedly raped
by three men while she was away from her residential care unit.
The investigation found Child Protection had moved Brittany many times because of her
needs and behaviours. It focused on her first two residential placements with Berry Street and
Anglicare. The evidence shows:
• Berry Street accepted Brittany in one of its units with an older girl who had a history of
significant mental health issues. It thought the girl would act like an older sister. But Brittany
started mimicking the older girl’s behaviours, including self-harming and misusing drugs.
• Three months later, a Berry Street worker witnessed the two girls kissing, and Child
Protection agreed to move Brittany.
• After Brittany moved to an Anglicare unit, Anglicare accepted another girl who was also
at risk of sexual exploitation. They started running away and Brittany told workers she
was getting explicit text messages from men.
• Brittany later told workers she had been raped twice – once by an adult man in an
apartment, and another time by three adult men after she and the other girl ran away at
night. Regarding the first alleged rape, Police said Brittany did not make a statement and
there were insufficient details for it to investigate. The second is before the courts.
Figure 10: Brittany’s timeline of key events
Berry Berry Motel with Anglicare January to December - 11 placements Brittany returns
Street Street Berry residential including home, kinship , foster care, home and then
residential residential Street care unit motels, residential care and Secure Welfare back to residential
care unit care unit workers care
Secure
Secure
Welfare
Welfare
2017 2018 2019 2020
9 Incidents -
absconding
and/or self-harm
Report to Children’s
Child Court
Protection makes Sexual assault Rape Gang rape
- Brittany Protection incident - incident - incident -
10 years Order co-resident community community
old in need
of protection

318. Brittany is in her early teens and the 323. Brittany and her sibling initially lived
youngest of the five children in this report. with their mother’s extended family,
She has been in and out of residential care but Brittany’s carers struggled with
since 2018, when she was 11 years old. her behaviour. Child Protection records
described Brittany’s behaviour as ‘very
319. In January 2019, a concerned family friend sexualised’ and said she sometimes
contacted the Ombudsman and said propositioned unknown adult men. It
Brittany had allegedly been raped by three also referred to suicide threats, violence
adult men while away from her residential and ‘extreme melt-downs’. By mid-2018,
care unit. The friend said Brittany’s mother Brittany’s family placements had broken
found out about the alleged rape from down.
one of Brittany’s friends via Facebook and
was experiencing ‘every parent’s worst 324. Child Protection began looking for another
nightmare’. option. At this stage, Brittany was 11 years
old and a Children’s Court Magistrate
320. Brittany has moved many times since expressed concern about moving her into
going into care. The investigation looked residential care given her age and care
at her placements with Berry Street needs.
and Anglicare. To understand Brittany’s
experience, the investigation: 325. Child Protection’s Placement Referral
document said Brittany needed:
• examined records from Brittany’s
Child Protection, Berry Street and a carer with knowledge of child trauma
Anglicare files who can offer appropriate supervision
and management of challenging
• obtained written responses from the behaviours.
Department, Berry Street, Anglicare
and Police Berry Street placement
• interviewed one representative from Placement risks
Berry Street and Anglicare, and three
Department representatives. 326. In mid-2018, Child Protection placed
Brittany in a Berry Street standard two-
321. The investigation confirmed risks to bed residential care unit.
Brittany escalated after she went into
residential care, and there are records of 327. There was only one other child living in the
three alleged sexual assaults during her unit. She was an older girl who had been
time with Berry Street and Anglicare. virtually the sole child in the unit for two
The investigation looked at what the years because of her significant mental
Department and CSOs did to manage health issues, including a history of self-
these risks and keep Brittany safe. harm.
328. Berry Street uses a written ‘matching tool’

Why Brittany was in residential care for placements but could not provide
322. Brittany grew up in Melbourne with her a copy to the investigation for Brittany.
mother and a younger sibling. When The Berry Street representative said at
Brittany was 10 years old, Child Protection interview that workers completed the tool
received reports that her mother could not but did not save it.
meet the children’s needs due to her drug
use. Child Protection obtained a Children’s
Court order to remove the children from
their mother’s care.
329. Berry Street told the investigation it 335. Records from a Berry Street internal review
believed the match was suitable because of the incident said it raised concerns
the other girl ‘did not have a history of ‘promptly’ with the Placement Unit.
high-risk behaviours that aligned with the
behaviours outlined in [Brittany’s] referral’. 336. The following day, Brittany and the
It said it hoped the girls’ relationship would other resident went missing again and
resemble an ‘older and younger sibling told workers they had overdosed on
relationship’. prescription medication. Berry Street’s
incident report said it would contact the
330. In response to the draft report, Berry Street Child Protection Principal Practitioner
said it placed a night supervisor in the unit (a senior expert in the Department) to
to enhance staff capacity overnight. It said discuss the ‘suitability of the current
Brittany appeared to have settled well and placement’.
had a good relationship with the other
resident in the first few days. 337. Child Protection did not take any
immediate action to end the placement,
331. However, records show Brittany and the however, and Brittany remained in the unit.
other girl started absconding together the
following month. They spent long periods Alleged sexual assault
of time absent from the unit on multiple
338. Almost three months after Brittany
occasions. The other girl told Berry
moved into the unit, a Berry Street worker
Street workers that older men sometimes
observed Brittany and the other girl
approached them, and she feared Brittany
‘making out’ on the couch. Brittany was
may have ‘gone off’ with these strangers if
still 11 at the time and the older girl was 17.
she had not intervened.
339. Berry Street’s report said it contacted a
332. Brittany and the other girl also
specialist Police unit, which advised:
told workers they were misusing
pharmaceutical drugs. Brittany threatened the action of passionately kissing in itself
self-harm and suicide on several occasions was not a criminal offence; however, if
and was placed into Secure Welfare two [Brittany] wanted to make a report, it would
investigate due to the age difference.
times for her own protection.
340. Police told the investigation it checked
333. Within two months, the children’s
with three local specialist units and there
behaviour had escalated. A Berry Street
was no record of the incident or such
incident report said the other girl was
advice to Berry Street.
hospitalised twice in three days with ‘out
of character’ medication overdoses and 341. At interview, the Berry Street
Brittany developed ‘increasing high-risk representative acknowledged that due
mimicking behaviour’. to the age difference between the girls,
it should have arranged ‘a secondary
334. Berry Street and others began questioning
consult’. The representative also said that
Brittany’s placement in the unit. After
upon reflection, Berry Street should have
Brittany was hospitalised due to
classified the incident as ‘major’ and a
threatening self-harm, a Berry Street
‘sexual assault’ in its incident report.
worker wrote:
The hospital did raise concerns regarding 342. In response to the draft report, Berry
[Brittany] being transported back to her Street said ultimately the Department
current placement, due to her identifying determines if incidents are categorised
feeling ‘unsafe around her co-young correctly. It said it asked Child Protection
person and unloved’. to move Brittany following the incident.

343. The next day, Child Protection and 349. Anglicare’s response to the draft report
Berry Street decided to end Brittany’s said it ‘was not included in any planning or
placement. For three weeks, Brittany Care Team meetings’ regarding the girl’s
stayed in a motel with Berry Street workers return to the unit. It said the girl’s return
while Child Protection sought a new was solely authorised by Child Protection.
placement.
350. However, emails show Anglicare agreed
to accept the girl back into the unit,
Anglicare placement
with reservations (see Figure 11 on the
Placement risks next page). At interview, the Anglicare
344. Towards the end of 2018, Brittany moved representative said they considered the
into an Anglicare standard four-bed risk to Brittany and thought the new girl
residential care unit with two other girls. would not take other children with her if
she absconded again.
345. Anglicare does not have a written
‘matching tool’ for placements. At 351. The Anglicare representative said
interview, the Anglicare representative said Anglicare planned to:
it discusses placements with Placement keep the young girls separated if possible
Unit staff and consults the CSO that with [the new girl] engaged with her
managed the child’s previous placement, if family and [Brittany] engaged with staff at
any. the house.
346. In a written response to the investigation, 352. The representative said this plan broke
Anglicare said it thought Brittany was a down fairly quickly because the new girl
suitable match for the unit. Amongst other stopped engaging with her family.
things, it noted the two other girls were
353. Brittany’s behaviours worsened. Anglicare
a similar age to Brittany and did not have
daily case notes show Brittany and
any sexual exploitation risks.
the new girl discussed running away
347. However, a month later, Anglicare accepted together two days after the girl returned
a fourth young girl who, according to from Secure Welfare. Anglicare workers
Child Protection records, had a ‘very high dissuaded them by taking them for a
risk’ of sexual exploitation. The placement drive. However, Brittany ran away on other
proceeded as an interim placement. At occasions. Records show she sometimes
Anglicare’s request, Child Protection said she drank alcohol or used illicit drugs
funded extra staff to supervise this new girl during these absences.
and reduce the risks to Brittany.
354. Anglicare told the investigation it held
348. The new girl ran away on her second three Care Team meetings for Brittany. In
night in the unit and moved temporarily to response to the draft report, it also said it
Secure Welfare. Before the girl returned, ‘called placement breakdown’ for the new
records show Brittany’s Child Protection girl, after the first alleged rape (see next
worker and an Anglicare worker both page), and Child Protection agreed to fund
raised concerns with their respective an extra worker for the unit to manage the
organisations, about her return. They raised situation.
Brittany’s risk of sexual exploitation and the
new girl’s potential influence on her.
Figure 11: Email from Anglicare to Child Protection, 20 November 2018
Anglicare worker
DHHS and Anglicare workers
20 November 2018
RE: Placement update for [other girl]
Brittany
Source: Department of Health and Human Services record of an email from Anglicare
Alleged sexual assaults 359. Brittany spoke to a Child Protection worker

and said she had been raped by three
355. About six weeks after Brittany moved to
adult men during the night. She said the
the Anglicare unit, she told workers she
men gave her and the other girl alcohol
had been raped on two separate occasions
and cannabis.
while away from the unit.
360. Anglicare completed an incident report
356. Anglicare’s incident report for the first
and contacted Police, who spoke with
assault said Brittany told a worker she
Brittany. This matter is before the courts.
was drugged and raped by a 24-year-
old man at an apartment in the city. She 361. Child Protection and Anglicare held urgent
would not provide information about the meetings that day. Child Protection agreed
date, so it cannot be confirmed if this to move the new girl from the unit and
occurred during her time with Anglicare. In Anglicare took Brittany’s phone to prevent
response to the draft report, Anglicare said further contact between them. In response
its records show the worker first became to the draft report, Anglicare noted the
aware of this incident by overhearing new girl’s placement ended at its insistence.
Brittany’s disclosure to another resident. Child Protection paid for a staff member to
follow Brittany if she left the unit.
357. Police confirmed Anglicare reported the
alleged rape. It said that Brittany did
not make a statement and there were
insufficient details for it to investigate.
358. The second alleged rape occurred after

Brittany and the new girl went missing
from the unit at about 11pm one night.
Anglicare workers followed them in a car
but lost sight of them. Anglicare reported
both children as missing to Police and
Child Protection. Early the next morning,
the girls returned to the unit on their own.

Other concerns 366. Records show Berry Street workers went
out looking for Brittany when she went
Sexual exploitation risk
missing, and lodged incident reports. They
362. The investigation also looked at how also show Berry Street agreed to develop a
Child Protection and the CSOs managed ‘calendar’ of activities for Brittany separate
Brittany’s absconding from her residential from the other resident. Berry Street and
care units, given her age and identified the Department said the Department also
risks of sexual exploitation. funded an extra worker for the unit.
363. The month after Brittany moved into 367. At interview, the investigation asked the
residential care, Child Protection gave Berry Street representative how Brittany
Berry Street a Care Plan with advice about was able to run away from the unit so
how to respond. It said, given Brittany’s often, even with extra supervision. The
age and vulnerabilities, workers should call representative explained:
000 immediately and report her to Police
One of the difficulties about residential
as a missing person (see Figure 12 below).
care is that we can’t stop young people
Berry Street’s own Care and Safety Plan from leaving placement. All we can
for Brittany contained the same advice. do is encourage them to try and stay
by providing activities that might be
364. Berry Street said Child Protection later more exciting than going out … if a
developed another Safety Plan. It advised young person wants to leave, we have
workers to give Brittany a 30-minute no recourse to stop them other than
window to return to the unit if she ran encouragement and support.
away alone, rather than immediately 368. In response to the draft report, Berry
contacting Police. Street said:
365. In response to the draft report, Berry its approach is to provide an environment
Street said this was Child Protection’s where young people want to be and
decision. It said Berry Street’s supervisor incentivise staying at placement, as well
in the unit believed the plan was meant as responding appropriately when they
are absent from placement.
to give Brittany time to ‘cool down’
and return to the unit voluntarily, rather 369. Brittany continued running away after she
than involving Police and escalating the moved to the Anglicare unit.
situation.
Figure 12: DHHS Care Plan for Brittany
If Brittany
Source: Berry Street
370. The Department said it had funded a Where is Brittany now?
second worker in the unit at night so
375. Child Protection moved Brittany 11 times
that Brittany could be followed if she left
in 2019, after her Anglicare placement
the unit. In response to the draft report,
ended. This included attempts to return
Anglicare said the extra staff member
her home to her mother and her extended
was ‘primarily to engage the [other girl
family, admissions to Secure Welfare,
at the unit]’. It also noted that while Child
and emergency stays in motels with
Protection’s new safety plan said additional
paid workers. Brittany then returned to
staff should be stationed outside Britany’s
residential care.
door to prevent her absconding, it ‘refuted
the feasibility of this’. 376. Brittany’s mother told the investigation
her daughter had returned home in early
371. Records show Anglicare workers took
2020 after going missing from residential
various steps when Brittany went missing.
care for about a month. Brittany has not
On one occasion, records say workers
been to school for about two years now.
tried to convince Brittany to stay in the
Her mother said she is working with Child
unit after she told them older men were
Protection to develop a home-schooling
contacting her with explicit messages and
plan to help Brittany catch-up and hopes
she planned to meet an older man in the
she can join some local youth groups when
city. On another occasion, they took the
COVID-19 restrictions permit so Brittany
girls on an outing to occupy them. On
can make some new friends and start
other occasions, they tried to follow the
enjoying life again.
girls.
377. Towards the end of 2020, Brittany returned
372. In one case, Brittany left the unit with the
to residential care while Child Protection
other girl after telling workers they planned
works with her and her mother on the best
to meet a man at a train station. Workers
option for her long-term care.
followed them to the train station and
noted there was no man waiting for them.
They watched the children board a train
The CSOs’ responses
but did not follow them onto the train. Berry Street
373. In response to the draft report, Anglicare 378. As this report noted earlier, Berry Street’s
stated this ‘implies staff had a choice not Chief Executive Officer accepted there
to board the train to follow the two girls’. were areas where it could have done better
It noted workers made the appropriate to care and advocate for the children in
notifications to Child Protection upon this report. They said Berry Street tried its
returning to the unit. best to deliver quality ‘care, supervision
and support within the ill-equipped and ill-
374. Anglicare completed incident reports designed residential care system’.
for some of the occasions Brittany went
missing, but not all. In response to the draft 379. As noted, the Chief Executive Officer said
report, Anglicare noted one absence was that Berry Street is now ‘much firmer’ in
in the middle of the day on a Sunday and: saying no to proposed placements when
there are clearly identified risks. It is also
there would be no expectation from reportedly doing more to support senior
Anglicare or DHHS that such an occurrence
staff and external investigators to manage
would be the subject of an incident report.
incident reporting.
380. Appendix 1 sets out responses from

Berry Street’s Board President and Chief
Executive Officer.

Anglicare
381. Anglicare’s Chief Executive Officer
provided a detailed response to the
draft report, so the investigation could
understand the context around Anglicare’s
care for Brittany and raised the following
issues with the investigation.
382. First, Anglicare said comments in the draft

report about incident reporting:
do not indicate an accurate understanding
… of the threshold required for an incident
report.
383. Anglicare said that Child Protection’s

incident reporting guidelines
outline that if an event or circumstance
had the potential to cause harm to a
client but did not do so [Anglicare’s
emphasis] it does not meet the threshold
required to complete [an incident] report.
384. The investigation notes the missing

incident reports related to Brittany being
absent from the unit after receiving
sexually explicit messages from an adult
man wanting to meet her. The incident
guidelines state ‘an absent client’ incident
is one in which the child is ‘absent without
authorisation and there are concerns for
their safety’.
385. Second, Anglicare did not accept there

were problems with its risk management
or supervision of Brittany. It said it worked
closely with Child Protection to follow
safety plans and endorsed risk mitigation
strategies, including rostering additional
staff in the house at night, after which no
further significant absences occurred.
Avery
Avery has been in residential care since 2018, when she was 13 years old. She has been
diagnosed with an autism spectrum disorder and complex behavioural disorders. She lived in
two different Berry Street units during her first year in residential care.
In 2019, Avery’s mother contacted the Ombudsman saying that Avery had been raped by an
adult man while away from her residential care unit. She also said Avery had started using
illegal drugs and self-harming. The investigation found:
• At first, Avery was meant to be the only child in her unit because of her complex needs
and behaviours.
• Berry Street said Child Protection pressured it to accept other children in the unit. After
this, Avery’s behaviour deteriorated and she began using drugs.
• Around five months after going into care, Avery was raped by an adult man at his home.
Police told the investigation the man was found guilty at court and is currently appealing
his sentence. Avery has since been hospitalised many times after self-harming.
• Avery also reported that one of the other children in her unit assaulted her three times.
• Child Protection and Berry Street moved Avery to another Berry Street unit where she
was once again the only child. However, problems continued.
• Berry Street told the investigation there are growing numbers of children with complex
disabilities in residential care. It said the system was not designed for these children and
more support is urgently needed.
Figure 13: Avery’s timeline of key events

Avery placed with new
2nd Berry Street Returns to 2nd Berry
Berry Street Community Service
residential care Street residential
residential care unit Organisation, only child
unit care unit
in residential unit
Secure Secure Secure

Welfare Welfare Welfare
Complaint
about
access to
pet for
therapy
2018 2019
Rape incident - Physical Physical assault

Report to community assault incident x 3 –
Children’s Court
Child incident - co-resident
makes Protection
Protection - disability
Order
Avery 13 agency
years old in worker
need of
protection 30 self-harm incidents from Other incidents of absconding, school issues,
mid-2018 to mid-2019 misuse of drugs and harm to others

386. Avery is in her teens and has been in 392. Child Protection was involved with
residential care since 2018, when she was Avery and her family throughout Avery’s
13 years old. childhood. It attempted to help the family
through disability, mental health and family
387. In March 2019, Avery’s mother contacted support services.
the Ombudsman and said Avery had been
raped by an adult man while away from her 393. In 2018, Avery’s mother had become
residential care unit. She also said Avery had worried that Avery’s aggressive behaviour
started drinking and using drugs and had was placing herself and Avery’s younger
attempted suicide several times. She said siblings at too much risk. Child Protection
residential care workers were ill-equipped to removed Avery from the family home.
respond and she was:
394. At first, Child Protection tried to place
desperate for her daughter to be provided Avery with extended family, but they
with the treatment and education she struggled to manage Avery’s behaviour
requires before she ends up in juvenile
and needs.
[detention] or dead.
395. After exhausting other options, Child
388. The investigation found Child Protection
Protection looked for a residential care
had placed Avery in two different
placement for Avery. Its Placement Referral
residential care units, both managed
document said Avery needed ‘2:1 care
by Berry Street. To understand her
support’ because of her behaviours. This
experience, the investigation:
meant Avery needed two workers solely
• examined records from Avery’s Child dedicated to her care.
Protection and Berry Street files
• obtained written responses from the Berry Street placements
Department, Berry Street and Police Placement risks
• interviewed one Berry Street 396. Child Protection moved Avery into a Berry
representative and three Department Street standard residential care unit in
representatives, including a Child 2018.
Protection Principal Practitioner
397. At first, Avery was the only child in the
• spoke with one of Avery’s former
unit. Berry Street provided 2:1 care in
psychologists by telephone.
the daytime. It only provided 1:1 care
389. The investigation looked at what Child at night. In a written response to the
Protection and Berry Street knew about investigation, Berry Street said this was
the risks to Avery and how they responded. because ‘[the Placement Unit] would not
provide additional funding … despite the
Why Avery was in residential care information in the placement referral’.
390. Avery’s childhood was marred by 398. Berry Street said it accepted Avery on
significant family violence, including an the condition she would remain the only
incident during which Avery’s mother said child in the unit for three months ‘in
the father tried to kill her and abduct Avery response to the high level of complexity
and her younger sibling. that [she] presents with’. However, it said
the Placement Unit soon began asking
391. Avery has been also diagnosed with an
it to accept other children. It said the
autism spectrum disorder, attention deficit
Placement Unit was:
hyperactivity disorder and oppositional
defiant disorder. Her conditions result in insistent Berry Street recommence taking
some challenging behaviours, including referrals at the unit with no real evaluation
of the three-month trial period.
self-harm and violence towards others.
399. In response to the draft report, Berry 402. Berry Street said it completed ‘matching’
Street said it repeatedly refused assessments for all of the children, but
requests from the Department to accept they were ‘not saved on file’.
other children in the unit. It said it also
advocated for a ‘specialised model of care’ 403. Avery’s mother and a public hospital
for Avery. It said the Department rejected psychologist both raised concerns about
its requests and ‘described Berry Street as these placements. They said Avery
“risk averse” compared to other CSOs’. mimicked other children’s behaviour and
Avery’s mother was worried her daughter
400. Three months after Avery moved to the would be exposed to drugs and alcohol.
unit, Child Protection and Berry Street The psychologist told the investigation that
started placing other children in the unit. ‘a traumatised kid with extreme behaviours
Then, over the next four months, six other definitely should not have been placed
children came in and out of the unit. These with [Avery]’. Avery’s mother said she
placements ranged from one night to four thought Avery was going to be the only
months. They meant Avery was no longer child in a therapeutic unit.
receiving 2:1 care.
404. Child Protection records show Child
401. Some of these children also had Protection told Avery’s mother that
challenging behaviours. One child had a ‘residential placements are not for one
history of drug use. Another allegedly had child only’ (see Figure 14).
a history of assaulting family members.
Figure 14: Child Protection case note of phone call from Avery’s mother, 15 February 2019
Avery
Child Protection Practitioner
Mother
Mother Avery Avery

Avery
Mother Avery
Avery Avery
Avery
Mother Avery

405. The Department told the investigation: Sexual assault – rape
The demand for residential placements is 409. Around five months after moving into the
significant and the support requirements unit, Avery told workers she had been
for children being considered for raped by an adult man.
residential care are often complex and
challenging. Amelioration strategies are 410. Incident reports show Berry Street workers
put in place to mitigate the risks posed
allowed Avery to leave the unit to meet
by [children] to each other such as safety
plans and behaviour management plans. friends, on the condition she would go to
a meeting at her school and then visit her
406. At interview, Child Protection’s Principal mother. She later called workers and said
Practitioner said Berry Street assured she had taken the drug MDMA and was
Child Protection it would have experienced planning to go to the house of a 23-year-
staff working with Avery in the first three old man who had given her alcohol.
months, so they could introduce more
children to the unit. They said Berry 411. Workers tried to dissuade Avery but did
Street said it would have its ‘best staff, not notify Police. They say they went to
handpicked, the best team possible’ and a train station where Avery was heading.
they would all be Berry Street employees They did not arrive for over two hours,
with a minimum of three-years’ experience. for reasons that are not explained in the
records.
407. However, within days Berry Street rostered
agency staff to care for Avery. In response 412. Two hours later, after a number of phone
to the draft report, Berry Street said it did calls from Berry Street workers to Avery,
not make any such assurances regarding she called workers in tears and told
staffing in Avery’s unit. them where to collect her. She gave
unclear details about an incident with the
408. Berry Street’s records contained several man. Workers notified Police and Child
safety and behaviour management plans Protection. Avery told her Child Protection
for Avery, as well as expert advice. However, worker the man raped her.
records show her behaviour deteriorated.
She began using illegal drugs, running away 413. Police told the investigation the man was
and continued acting aggressively towards found guilty at court and is currently
herself and others. She was suspended appealing his sentence.
from school and had frequent contact with 414. Berry Street conducted its own ‘quality of
Police and hospitals. At one point, two new care’ investigation into its actions. It did
children moved into the unit in the same not identify concerns with its care and said
week. Berry Street said this led to eight the worker had more frequent contact with
‘major incidents’ in five days. Avery and her mother than shown in the
records. It did not identify workers’ failure
to notify Police when Avery told them
she had taken drugs and alcohol and was
going to the man’s home.
Alleged physical assaults 421. Avery told a Berry Street worker the
agency worker:
415. Around six weeks later, Avery’s mother told
Child Protection and Berry Street that a scares her and that if she sees him again,
new child in the unit had assaulted Avery she will hurt herself … and that she prefers
three times. The alleged assaults involved: having female staff on at night.
• pushing Avery 422. Avery’s preference for female workers

was documented in Child Protection’s
• threatening to ‘punch [her] in the head’
Placement Referral.
• slapping and punching her ‘several
times to the head’. 423. Berry Street’s investigation found Avery
assaulted the worker and tried to choke
416. Berry Street lodged incident reports for him. Police charged her with assault, but
two of these incidents. It later changed the charges were later struck out.
one after wrongly classifying the incident
as ‘non-major’. 424. The internal investigation did not
substantiate Avery’s counter-allegation
417. There is no record of Berry Street that the worker assaulted her. However,
submitting an incident report for the it identified the worker was not properly
second alleged assault. In response to the trained. It stated:
draft report, Berry Street said:
It is the belief of the investigator that due
[T]here is no record in its (contemporaneous) to [the agency worker]’s lack of training
case notes that an incident with [another around de-escalation, that he resorted
child in the unit] occurred on [date to restraint in order for him to restrict
redacted]. Berry Street’s records do, [Avery’s] further assaults … the approach
however, refer to [Avery] becoming [the agency worker] took [indicates]
increasingly distressed at having to share that he did not know how to respond to
her space with another young person and [Avery’s] cues and behaviours and he was
threatening the other young person. not able to de-escalate.
418. Police advised the investigation they did not 425. The Department’s Minimum Qualification
receive reports about any of the incidents. Strategy for Residential Care Workers in
Victoria policy requires CSOs to allocate
Alleged assault by agency worker tasks to workers that are appropriate for
the worker’s skill level and education.
419. The investigation also identified records
of an earlier alleged assault involving a 426. Berry Street’s report on the incident said
temporary agency worker. Avery claimed the worker’s agency would review ‘his
the worker choked her following an placement into units that are appropriate
incident in the unit. for his level of experience’. It did not
question Berry Street’s decision to roster
420. A professional who was visiting the unit
agency workers in the unit.
at the time told Berry Street’s internal
investigator she witnessed a disagreement 427. In response to the draft report, Berry
between the agency worker and Avery Street said its investigation, which was
over Avery’s behaviour. Avery tried to endorsed by the Department, found ‘there
follow the worker into the unit office, and was no evidence of a physical assault,
he pushed the door onto her foot to stop inappropriate physical treatment or poor-
her. Avery ‘gave him a finger gesture and quality care’ towards Avery. It said it is
he returned the gesture’. A few days later, not part of the investigation’s scope to
Avery said the worker tried to choke her. determine if it should have used agency
workers.

428. Berry Street did not notify Police of 433. However, problems continued. After
Avery’s assault allegation until four days around four months, Berry Street decided
after the incident. Berry Street said it could no longer care for Avery. In
the delay was ‘due to a worker error in response to the draft report, Berry Street
originally classifying the report as a non- said it ended the placement because Avery
major [incident] report’. It also said it has would benefit from specialist disability
since centralised oversight of incident support that it could not provide.
reporting. Its central team now supports
workers to comply with incident reporting Other concerns
requirements, including advising workers
434. The investigation also identified other
when to report matters to Police.
concerns and observations about Avery’s
time in residential care.
Placement changes
429. In April 2019, Berry Street decided to Need for therapeutic care
end Avery’s placement in the unit. The
435. When Avery’s mother contacted the
Department said Berry Street made
Ombudsman, one of her main concerns
the decision because of ‘the level of
was the lack of a therapeutic approach to
supervision required for monitoring
her daughter’s care. She wrote:
[Avery’s] self-harm and high-risk
behaviours’. Berry Street indicated it could Since being in Child Protection care
not care for Avery under the arrangements [Avery] has been neglected and exposed
‘as it was too unsafe’. to drug use, self-harm, been raped (Vic
Police have charged perpetrator and he
430. Child Protection moved Avery to Secure is pleading guilty), assaulted by another
young person in the unit …
Welfare. Twenty-four hours later, Berry
Street agreed to care for Avery again at After [Avery’s] sexual assault [Avery] was
a different unit, with extra funding for a strangling herself on a daily basis and
higher level of care. ending up in the Emergency Department.
As a result of mismanagement, neglect

431. Child Protection records show there was
and [Avery’s] disability and emotional
an ‘urgent planning meeting’ about Avery’s needs not being meet, [Avery] ending up
care. The notes state a four-bedroom unit being put into Secure Welfare twice for
was unsuitable for Avery and that other long periods at a time.
children in the unit could not ‘tolerate her
[Avery] has now been placed into another
presentation’. Child Protection and Berry unit by herself … Staff were trained by [a
Street decided to move her to a standard consultant]. The recommendations are
two-bed unit, where the workers had to support [Avery] with therapeutic
success with children with autism. Records treatment.
say Avery was to be the only child in the
This didn’t happen, [Avery] had irregular
unit and would receive 2:1 care in the staff, no routine, [Avery’s] therapeutic
daytime and 1:1 care at night. needs not being meet and [Avery] not
feeling safe with different staff. This
432. Berry Street scheduled training for the unit resulted in [Avery] assaulting staff,
workers while Avery was in Secure Welfare. smashing … windows and putting herself
They visited Avery daily until she was at risk by walking on a main road in
ready to move to the unit. front of oncoming traffic. Threatening
self-harm. It is well documented that
these behaviours are an outcome of how
severely distressed [Avery] is.
436. Records confirm Avery’s behaviour 441. Records show Child Protection and
deteriorated in residential care, despite medical and behavioural specialists had
many plans and expert advice about agreed a pet would ‘make a dramatic
her behaviour and needs. While she had improvement [to Avery’s] therapeutic
behavioural problems before entering care, treatment’. The Ombudsman raised
there was no record of her using illegal the matter with the Department, which
drugs or self-harming. reached an agreement with Berry Street so
Avery could keep one of the kittens.
437. Avery’s former psychologist told the
investigation that Avery came into care 442. In response to the draft report, Berry
with some ‘baggage’ but: Street said it had supported visits to the
unit from Avery’s family dog until the
she never took drugs before, she
didn’t abscond, and she hadn’t been
dog bit a staff member. It said the kittens
raped … when you have information were brought into the unit without prior
about a disability, and you ignore it, approval and a worker in the unit had a
the negligence is way worse than the serious allergy to cats. It said this worker
kid’s baggage when they come into the had consequentially been rostered to a
system.
different unit.
438. At interview, the Berry Street
443. In response to the draft report, Avery’s
representative said Child Protection did
mother told the investigation when her
not give Berry Street a referral to provide
daughter had ‘melt-downs’ following the
therapeutic care to Avery. They said Berry
rape she was often restrained and sedated
Street engaged well with Avery’s mother
by emergency services. She said Avery was
and ‘cared well’ for Avery, but there
usually refused admission to mental health
needed to be better scrutiny of placement
hospitals as it was deemed a ‘behavioural’
decisions.
problem. Instead, Avery was placed into
439. In response to the draft report, Berry Secure Welfare, despite her expressing
Street also noted that, even if Child she was suicidal and even jumping in
Protection had placed Avery in a front of cars. Avery’s mother estimated
therapeutic residential care unit, the these secure placements accounted for
current therapeutic residential care model 80 per cent of Avery’s time in care during
would not have met Avery’s needs. It said a 10-month period in 2019. She said this
the model is not disability-specific and is not where a child with a disability
Avery would still have lived with other recovering from trauma should be.
children. Berry Street said it provided
‘care with therapeutic input’ to Avery by Medication and possible chemical restraint
advocating for her to be placed in a unit 444. The investigation observed that, as
by herself, declining five attempts to place with Quinn, there was some evidence
other children in her unit, and working suggesting Avery was given medication to
with specialist services to implement a manage or control her behaviour.
personalised therapeutic plan.
445. Berry Street’s written response to the
440. When Avery’s mother contacted the investigation said it had identified some of
Ombudsman, she was particularly Avery’s prescribed medications met Berry
concerned that Avery needed a Street’s definition of ‘chemical restraint’. Its
therapeutic pet. She said Avery had taken definition:
in two stray kittens, but Berry Street was
planning to remove them. includes any drugs … that have an effect
upon an individual’s cognitive functions, and
whose prescribed intent is to affect or alter
thought processes, mood or behaviour’.

446. Some of Avery’s records indicate doctors Berry Street’s response
prescribed her medication to manage
452. As noted earlier, Berry Street’s Chief
changes in her behaviour.
Executive Officer accepted there were
447. There is no record that Child Protection or areas where it could have done better to
Berry Street asked doctors to clarify the care and advocate for the children in this
purpose of the medication. report.
448. The Department told the investigation it 453. In response to the draft report, Berry
was not aware of any chemical restraints Street noted the Department used to
for the five children in this report. fund specialised disability group homes
for children. It said the Commonwealth
449. In response to the draft report, Government has not continued support
Berry Street said all medication was for those homes under the new National
administered in accordance with the Disability Insurance Scheme.
doctor’s prescriptions. It said it has since
improved its procedures to bring them 454. Berry Street said children with disabilities,
in line with best practice. It said there are such as autism spectrum disorder and
increasing numbers of children with a intellectual disabilities, are now living in
disability entering care and administering general residential care. It said residential
medication for those children is a care was:
relatively new skill for residential care not designed to meet the needs of these
workers. children and staff do not have the core
skill-base or training needed to meet
Where is Avery now? their complex disability related needs in a
comprehensive way.
450. In December 2019, Child Protection told
the investigation that an experienced CSO 455. Berry Street said it has been training its
had taken over Avery’s care. She was the workforce to respond better. It said it has
only child in her unit and was getting extra received no support or additional funding
disability and mental health support. from relevant government agencies or
through the disability sector. It said this
451. In August 2020, Avery’s mother told the support is required urgently.
investigation Avery had been attending
school for half a day each day and work 456. Berry Street also said for the majority of
experience in the afternoons. However, incidents outlined in this report, it ‘made
her work experience had been restricted appropriate and timely incident reports’.
recently due to COVID-19 and Avery was Berry Street acknowledged that some
now spending afternoons with her mother reports were incorrectly categorised,
at home. Avery’s mother said Avery but said this should be understood in
was being ‘chemically restrained’ at her the context of a relatively new reporting
placement after a series of ‘meltdowns’, system and the interpretation of reporting
limiting the types of services she can requirements evolving over time. As
access to bring her daughter home. noted earlier, Berry Street said it recently
Avery’s mother continues to advocate for undertook extensive work to support
her daughter’s care. senior staff and external investigators to
manage incident reporting.

Executive Officer.
Alex
Alex is a young person in his teens with a complex history and behaviours, including mental
health conditions. He identifies as non-binary but prefers to be referred to using male
pronouns. One of his family members told the Ombudsman that Alex reported he was raped
by another boy shortly after going into residential care.
The investigation found Alex has been in and out of residential care since early 2019. It focused
on Alex’s first placement with Berry Street and two later placements with Junction. The
evidence shows:
• At first, Child Protection placed Alex in a Berry Street unit with three other boys. Alex told
Child Protection he was anxious because he had been sexually assaulted by adolescent
boys in the past.
• Records show unit workers allowed a younger boy to stay in Alex’s room overnight.
Although workers checked on the boys regularly, Alex later said the boy raped him. Police
advised they did not lay charges and Berry Street said its own internal investigation did
not substantiate the sexual assault.
• After Alex moved to a Junction unit, Child Protection and Junction placed a teenage boy
with a history of criminal offending in the unit.
• Alex and the other boy started running away together and using drugs.
• Alex was seriously assaulted by someone he said was his drug dealer and spent more
than 12 hours in hospital.
Figure 15: Alex’s timeline of key events
Alex placed with new

Junction residential 2nd Junction residential Community Service
Berry Street
care unit care unit Organisation in
residential care unit
residential care unit
Case
management
Kinship care Secure Secure Home contracted Secure
Welfare Welfare to Junction Welfare
2018 2019
Report to Children’s Physical Rape incident - Physical Physical assault

Child Court makes assault co-resident assault incident - worker
Protection Protection incident – incident -
- Alex 15 Order co-resident community
years old in
need of
protection

458. Alex is a teenager who identifies as non- 463. Alex’s mother began turning their lives
binary or gender-fluid and prefers to around. But when Alex was a teenager,
use male pronouns. His gender identity Child Protection became involved again
has been fluid during his placement in due to concerns about his behaviour. Child
residential care. He has lived in residential Protection records say Alex said he was
care since early 2019, when he was 15 drinking and using illegal drugs. Child
years old. He remains close to members Protection also said he was vulnerable to
of his family, including his mother and sexual exploitation. While Alex’s family told
grandmother. the investigation that reports of alcohol
and drug use were untrue, he told the
459. Shortly after Alex went into residential investigation he was drinking and smoking
care, one of his relatives contacted the ‘weed’. Alex had also been diagnosed
Ombudsman and said Alex alleged he with post-traumatic stress disorder and
had been raped by another boy in his oppositional defiant disorder. Records say
residential care unit. The relative said he had attempted suicide many times.
Child Protection said Alex and his family
had raised concerns with Child Protection 464. In late 2018, concerns for Alex reached
before it placed Alex in the unit. a crisis point and his mother felt it was
unsafe for him to stay at home. Child
460. Records show Alex lived in three Protection placed him with relatives and
residential care units during his first year in then returned him home with supports.
care – one managed by Berry Street and
two managed by Junction. These were all 465. However, Alex’s suicidal and other
in regional areas, several hours from Alex’s behaviours grew worse. In early 2019,
family. To understand Alex’s experience, Child Protection placed him in Secure
the investigation: Welfare for his own protection and began
looking for a residential care placement.
• examined records from Alex’s Child Alex’s relative says he was removed from
Protection, Berry Street and Junction the family for ‘no real reason’ and these
files decisions will have a detrimental and long-
• obtained written responses from the lasting impact.
Department, Berry Street, Junction
and Police Berry Street placement
• interviewed three Department Placement risks
representatives, one representative
from Berry Street and three Junction 466. In early 2019, Child Protection placed
representatives. Alex in a Berry Street standard four-bed
residential unit. Berry Street was the only
461. The investigation looked at what Child CSO providing residential care in the area.
Protection and the CSOs knew about the There were three boys already living in the
risks involved in Alex’s placements and unit when Alex moved in.
how they managed them.
467. Records show that Alex told Child
Protection he was ‘extremely anxious’
Why Alex was in residential care
about living with three males. A Child
462. Child Protection became involved in Alex’s Protection worker wrote:
family when he was a young child. Its
[Alex] stated that he becomes anxious
reports mainly describe family violence.
about being around males due to
historical assaults …
[Alex] further disclosed being raped by a 474. Berry Street’s records say workers
group of adolescent males, again within observed the younger boy putting Alex in
the last couple of years … [Alex] advised
a choke hold twice during the day. They
his belief is that these males did not know
if [Alex] was male or female, did not contain inconsistent accounts of what
accept his gender identity, and that this happened next.
precipitated the assault.
475. Berry Street’s incident report said the
468. Child Protection went ahead with boy stayed in Alex’s room overnight. The
the placement. It did not record the report said a worker asked the boy to leave
information about Alex’s reports of past ‘repeatedly’ but ‘he consistently refused’.
sexual assaults on his Placement Referral The report said the worker conducted
document. Berry Street said it was never welfare checks every 15 minutes and
told. observed both children asleep by 4:30am,
with Alex in his bed and the boy on the
469. Berry Street warned the Placement Unit couch in Alex’s room.
that one of the boys might target Alex
because of his gender identity. It said 476. However, Berry Street’s daily records
this boy (and possibly the other boys) say the worker checked Alex every 15
would ‘expose [Alex] to significant teasing minutes until 3am because he had taken
and threats’ because they ‘would not some unauthorised medication, and then
understand or be open to [his] non-binary checked him every 30 minutes. These
status’. records do not mention the boy staying in
Alex’s room.
470. At interview, the Departmental
representative said there appeared to be 477. Berry Street and the Department
some issues with the placement from a disagreed about whether Berry Street staff
LGBTIQ perspective. They said it may have should have done more to protect Alex.
been the only placement available for Alex, The Berry Street representative maintained
and the Department needs to provide at interview that workers checked Alex
more guidance to support best practice in every 15 minutes and said, ‘we can’t force
this area. young people out of [an]other’s bedroom’.
471. Alex’s relative said they also expressed 478. At interview, the Departmental
concern the placement would be unsafe representative said, ‘the reality is stand-up
for Alex but felt they ‘hadn’t been heard’. staff are funded at night for these reasons …
The relative said Child Protection assured not to act passively’. They said, if the worker
them ‘there would be 24-hour supervision’. felt unable to force the issue, they could
have moved Alex from the room for his
472. Child Protection did provide additional safety. The representative also said workers
funding so there would be two staff can call for back-up when required.
present at all times, even overnight.
479. In response to the draft report, Berry
Alleged sexual assault Street said it had given Child Protection
no assurances that there would be 24-
473. A few days after Alex moved into the unit,
hour, line-of-sight supervision, or that such
records say he became very distressed and
supervision could be provided. It rejected
workers sent him to hospital for suicide
the assertion that the level of supervision
assessment. He said he had been raped by
was inadequate or passive. It accepted it
a younger boy in the unit.
conducted checks every 30 minutes after
3am. However, it said at all times during
the night a worker was steps from Alex’s
bedroom in an office.

480. Berry Street promptly took Alex to a 487. Child Protection’s records note concerns
Police station to report the incident. about the boy’s potential ‘contamination’
Upon request, Berry Street gave Police of Alex. They noted the unit was ‘sleepover
Alex’s clothes and bedding, as well as an only’, meaning there would be only one
unwrapped condom that had been found worker in the unit at night and they would
under Alex’s mattress. Police have advised be asleep, unless needed by the children.
the investigation that they did not lay Senior managers indicated Alex should
charges. only be placed with the boy as a last
resort, and with extra workers to give Alex
481. In response to the draft report, Berry one-on-one supervision.
Street said its own internal investigation
did not substantiate the sexual assault. 488. Junction told the Placement Unit it could
provide ‘active’ supervision at night, at an
482. Two days after the alleged rape, Berry additional cost. It said it thought the match
Street told Child Protection the accused was suitable because the other boy had a
boy had previously touched female strict curfew and his history indicated he
workers inappropriately on two occasions. ‘would be on his best behaviour when he
The records say ‘there were thoughts’ by returned to the unit’.
the other boy’s Care Team that the boy’s
actions were ‘seeking maternal comfort 489. Alex told the investigation he did start
as opposed to problematic sexualised using the drug ‘ice’ with the other boy
behaviour’. while in this residential care unit and that
they both helped each other get drugs. He
483. Child Protection moved Alex to Secure said they are still friends, ‘like brothers’, but
Welfare, and then back home to his are now both now ‘clean’ and have helped
family. While at home, Alex made threats each other a lot.
of violence and self-harm; and Child
Protection began looking for another 490. In response to the draft report, Junction
residential care placement. said it provided ‘active night support’ on 37
out of 39 nights that Alex was at the unit
Junction placements during his first placement. However, it said
it was not included in initial discussions
Placement risks
about the need for one-on-one care. It said
484. The following month, Child Protection it did not have any vacant properties or
placed Alex in a Junction standard four- workers to provide such care.
bed residential unit in another area.
Alleged physical assault
485. At the time, there was only one other
resident in the unit, an older girl with a 491. A week after Alex moved into the unit,
disability who was preparing to leave State he called workers and said he had been
care. assaulted. He said he had gone out to
‘kill [his] drug dealer’ because the dealer
486. About one week later, Child Protection and sexually assaulted a child. A worker
Junction placed another boy in the unit, collected Alex. He was hospitalised for
who was around the same age as Alex. The over 12 hours due to his injuries.
boy had a history of criminal offending. At
interview, Junction’s representative said
the boy associated with drug users and
‘would happily take anybody with him’.
492. Junction’s incident report said a worker Alleged physical assault by worker
called the local Police Station to report the
499. Records show that a week later, at the
assault, but Alex did not want to make a
end of March 2019, Alex complained
statement and Police told the worker they
to Junction office staff that a worker
could not take any action. The incident
assaulted him during the night. Alex said
report did not name the Police officer who
he was hungry and tried to get into the
provided this advice.
unit office to get food, and a male worker
493. Police told the investigation they have pushed him against a wall or door.
no record of a report about the alleged
500. Junction carried out an internal
assault.
investigation but did not suspend the
494. The investigation raised this with the accused worker. One of the other children
Department and Junction during the in the unit also said the worker pushed
investigation. In February 2020, Police Alex. The worker agreed there had been an
told the investigation there had been no altercation but said they ‘tapped’ Alex on
subsequent report. the shoulder.
495. At interview, the Departmental 501. Junction’s investigation concluded the

representative said CSOs are expected to allegation was unsubstantiated. The
do what ‘you would expect a good parent investigator wrote in their report:
to do’ for a child. They noted Police can information supplied by [Alex] is at
take a report without the young person times fanciful which makes assessing
making a statement, and this should have information supplied by him difficult.
been pursued more vigorously.
502. In response to the draft report, the
496. The investigation also noted: Junction investigator said:
• Junction’s original incident report Upon investigation, which included

incorrectly classified the incident as the interview of the complainant and
witness, inspecting the scene and
‘non-major’. It did not re-submit the viewing documents, I found there was no
report to correct the mistake until evidence to support the claim of assault
early May 2019. and that the evidence supplied by [the
complainant and the witness] lacked
• Junction did not investigate the matter
credibility … there was no evidence to
or change Alex’s supervision. support the removal of the staff member
• Child Protection submitted a report … This investigation was concluded within
24 hours of the initial report.
to the Children’s Court the following
month about Alex placements. It did 503. Junction’s investigation report identified
not mention the alleged assault. the subject of the allegation did not record
497. In response to the draft report, a Junction the incident in their daily notes. It did not
representative said they asked Alex about identify that the subject of the allegation
the incident when speaking with him about failed to complete an incident report and
another matter in May 2019, and Alex inform their supervisor about the incident.
refused to provide a statement. A second worker who had learned of the
allegation the following morning also did
498. Alex told the investigation that he didn’t not inform the supervisor.
remember saying anything about the
drug dealer assaulting a child, but he was 504. Junction submitted an incident report
‘beaten up and nearly stabbed’ over a debt to Child Protection after Alex raised the
to this dealer. allegation with office staff.

505. Police told the investigation they did not 512. Junction’s records refer to:
receive a report about this incident. In
the difficulties of housing some young
response to the draft report, Junction said people together and how certain matches
a worker from the unit said they contacted can create an increase in criminal activity
Police. The representative said: of an individual, there was little staff could
do to prevent [Alex] from leaving the
That no report exists is an issue for Police. residence and putting [himself] at risk.
That no record exists in the LEAP system
is standard Police practice and the staff 513. Records show Child Protection and
member only erred in not obtaining a
Junction did not take steps to separate
name of the Police person she spoke to. If
she had obtained that name, there would Alex from the boy for some months.
still be no entry in LEAP.
514. At one point, Child Protection and
506. The investigation raised the lack of a Police Junction moved Alex to another Junction
report with the Department and Junction unit as part of a 'swap’ with a child who
during the investigation. In February 2020, needed to live alone. Junction and the
Police told the investigation there had Department said it was ‘more economical’
been no subsequent report. to move this child to the unit where Alex
and the boy had been living. But, instead
Other concerns of separating Alex from the boy, they
moved them together.
507. The investigation identified other concerns
about Alex’s care. 515. In its written response to the investigation,
Junction said:
Drug use and offending the placement decision was based on the
508. Records show Alex’s behaviour demands on placements across the state
as well as the best interests of [the other
deteriorated after he became friends with
child] … also DHHS requested to move
the boy in his Junction unit. Alex’s relative [the other child] to [Alex’s unit] as he
told the Ombudsman: would only be holding three targets to his
name instead of four.
[Alex] became friends with hardened
teenagers with violent criminal histories … 516. Junction was referring to the client
[he] is impressionable and naïve.
receiving solo care living in a residential
509. The relative said Alex is now facing serious care unit with capacity to accept four
criminal charges. children. It would cost the Department
less if this child was moved to a cheaper
510. At interview, a Junction representative also unit with capacity for only three children.
said Alex was often ‘busy with [the other If Alex and his co-residents moved to the
boy], doing drugs’ and they ‘did a run four-bed unit, there was the potential for
through’ on a friend’s home. another child to be also be placed in there.
511. Junction records show it was aware of the 517. Junction said discussions about moving
boy’s influence. Records of one incident the other child to Alex’s unit had begun
said Alex: before Alex moved in.
had engaged in dangerous activities 518. Around a month later, after further
since arriving at [Junction] and his
incidents, Child Protection decided to
relationship with [the other boy] has seen
an escalation in drug use by [Alex], [Alex] move Alex to Secure Welfare. At interview,
requires closer management by carers the Junction representative said:
and needs to be separated from [the
other boy]. we didn’t end the placement, the
professionals decided it was in [Alex’s]
best interests to go to Secure Welfare.
Medication and possible chemical restraint Where is Alex now?
519. The investigation observed evidence that 525. During the investigation, Alex’s relative
Alex, like Quinn and Avery, may have told the investigation that Alex was
been prescribed medication as a chemical ‘traumatised’ by the system meant to
restraint while in care. protect him and would live with the
psychological consequences for the rest of
520. Alex’s relative stated they had ‘asked his life.
constantly for a medication review’ and
mental health clinical support but none 526. Alex’s relative raised concerns that Alex,
was provided until Alex was in Junction’s who has dyslexia, had missed a year of
care. So, he ‘continued to spiral’. school while in residential care and he is
now so far behind that catching up seems
521. Alex’s records show doctors prescribed insurmountable. The relative is worried he
him several medications while he was has been ‘set up for failure’. Alex said his
in residential care, including an anti- schooling now consists of three solo one-
psychotic. The medication records viewed hour sessions with a teacher each week
by the investigation were sometimes but that it is hard to catch up.
unclear, but there is some evidence that
the anti-psychotic was used as a chemical 527. At the conclusion of the investigation,
restraint to manage Alex’s behaviour. An Child Protection said Alex is now living
email from a Placement Unit manager said in another residential care unit operated
the medication was to be given when Alex by another CSO. This unit is closer to
‘was heightened’. Alex’s family. Alex’s relative said trying
to visit when Alex was up to five hours
522. The investigation asked a Junction away (round trip) ‘was extremely difficult
representative whether Alex’s medications and often impossible [so it] made the
were used as a chemical restraint. The situation even more distressing’. They told
representative said there are no reporting the investigation that Alex is now much
mechanisms for chemical restraints happier, is re-engaging with his family, and
where children do not have ‘registered’ is forming positive social relationships.
disabilities. They said Junction had created
a medication policy but: 528. Child Protection’s records show it intends
to return Alex home at some point, but
found it really hard to get from the
Department something to guide [us]
there is no clear plan yet about how this
about what to do about chemical restraint. will be achieved.
523. In response to the draft report, Junction 529. Alex said he’s happy in his current
said it administers medication according residential care unit but is working towards
to the directions of the prescriber. It also renting his own flat with a friend. He
said the two Junction representatives is now linked with a drug and alcohol
interviewed by the investigation would counsellor but said he relied on his friends
not be fully aware of any child’s specific to help him deal with these issues in his
medications, as this is beyond the scope of other placements. He said that the best
their roles. thing about residential care is having a
comfortable bed, good food and a shower
524. Alex told the investigation he is prescribed but he’d like workers ‘that treat you more
an anti-psychotic medication for his like family’ and less like they are your
behaviour and he thinks that it helps. ‘manager’.

Berry Street’s response 536. The investigation has included additional
details in this report where relevant. It
530. Berry Street’s response to the draft report
has also checked the requirements for
reiterated the report’s position that the
reporting to Police and is satisfied they are
Child Protection and out-of-home care
accurately reflected in the report.
systems are:
characterised by placements based on
‘least-worst’ options rather than what is in
the best interests of children in its care.
531. It further noted the current system is

not meeting the needs of Victoria’s most
vulnerable children.

Executive Officer.
Junction’s response
533. Junction’s response to the draft report
clarified some of the details about Alex’s
care and the placement referral process.
The investigation has included those
details in this report.
534. Junction’s internal investigator provided

their own, separate response to the draft
report. The investigator said the response
was based on their own opinion ‘and is in
no way a representation of the opinions
of Junction’. They expressed a view that
the content of the draft report was ‘at
times over generalised, over-reaching and
unjust’ and lacked an understanding of
Police procedures. They said that while
there were some shortfalls, the portrayal of
Junction was ‘quite unfair’.
535. Junction’s investigator referred specifically

to the extent of Junction’s internal
investigations. They also stated:
Police are required to firstly identify that
an offence has been committed … [so]
minor assaults will only be recorded where
there is a victim prepared to provide
information and assist the investigation.
Wider problems and potential solutions
537. Evidence shows the experiences of the Wider problems
five children in this report are not new or
isolated.
Placement pressures
538. Over the last decade, many bodies 543. The evidence suggests there are pressures
have warned of significant and systemic on CSOs and Child Protection to place
problems with the residential care system children in residential care units, even when
– this office, the Victorian Auditor- the ‘match’ with other children may be
General’s Office, the Royal Commission risky or unsafe. Such placement decisions
into Institutional Responses to Child Sexual are inconsistent with the Placement
Abuse, the Institute of Child Protection Framework, which states, ‘the placement
Studies and CCYP. of one child should not jeopardise the
safety or individual needs of another child’.
539. CCYP’s most recent 2019 report on out-of-
home care, ‘In our own words’, found: 544. When the investigation asked CSO
residential care in its current form is often representatives why they accepted
unsafe for children and young people and children when there were risks, they
places them at an unacceptable risk of pointed to pressure from Child Protection.
harm.
545. A Berry Street representative said at
540. When ABC News asked the Minister for interview:
Child Protection if children were safer in
In mainstream residential care, there’s a
residential care than with their parents, he
lot more pressure just to take children.
responded: You might be told you have the only
Sometimes yes, sometimes no, it depends vacancy in the state … Just guessing, I
on the situation; there is no black and would say, you need to be at about 80%
white answer to that question (The lost capacity to match appropriately, and
kids, 4 March 2020). we’re at 95/100% capacity.
541. This section looks at the specific problems 546. A Uniting representative also referred to
raised by the evidence in this investigation: the pressure faced when the agency has
‘the only vacancy in the region or the
• placement pressures state’. They described an:
• flawed care and supervision often … heated conversation as the
• incident reporting mistakes pressures for the Department are to place
children and the pressures for agencies
• neglected cultural planning for are to care for children in a safe way.
Aboriginal children Sometimes those don’t match, and it can
be difficult.
• potential chemical restraint of children
• inadequate support for LGBTIQ children.
542. It also looks at two potential solutions to

some of the most difficult issues.
wider problems and potential solutions 71

547. A VACCA representative said Child 552. In CCYP’s 2015 report on residential care,
Protection asks VACCA to accept the “…as a good parent would…”, CCYP found:
highest-risk Aboriginal children when they
are an unsuitable match for VACCA’s unit • there was inadequate assessment of
and other children: the suitability of placements
• the mix of children in residential care is
We get the referrals for the young kids
they don’t know what to do with. Then
sometimes inappropriate
all of a sudden its ‘oh they’re Aboriginal • it seems the availability of beds, rather
and they need to be placed with you than the child’s best interests, dictates
guys, you have a responsibility to your
most placement decisions.
community’ …
They’ve got nowhere for that young 553. In response to the draft report, Berry Street
person to go, they’re so high risk no other made similar observations. It said the:
agency wants to take on the risk. So, we
often get referred young people who are current system fails because it is focussed
not right for the placement, they’re not on providing children with a bed and
safe to be matched with [others in the supervision, rather than the specialised
home], but we are kind of forced into the care and stability needed by a child.
situation because culture is used as the
reason. In my opinion its often kind of an 554. It noted that there is often disagreement
incorrect use of the Aboriginal Placement between Child Protection and the
Principle. Placement Unit ‘regarding placement
decisions that are based on resources
548. When the investigation asked Child rather than the best interests and needs of
Protection representatives why Child the child’. It also said:
Protection placed children in units where
there were risks, they pointed to the lack of capacity, flexibility and diversity
pressures on the Child Protection system of residential (and home-based) options
… forces Child Protection and CSOs to
and its workers. make decisions based on the ‘least-worst’
option available.
549. One Department representative said:
[Y]ou can only achieve [best practice] if Level of care
the system is resourced for best practice.
555. The five cases in this report also raise
… the reality is that the [Children’s] Court questions about the level of care available
has ordered that [the child] has to be
for children with complex needs and
placed in [out-of-home care], and that
will trump any other guideline … at the behaviours.
end of the day you have to have that child
in a bed … it’s an issue of prioritisation and
556. In a written response to the investigation,
compromise … everyone who works in it the Department described the needs of
attempts to meet their obligations. children in residential care:
550. The representative said: Children and young people in residential care
have experienced abuse and neglect, and in
you need to run a service at all times with many cases significant and enduring abuse
some capacity in order to do appropriate and neglect. The impact of this trauma may
matching, planning and ensure safety, and lead the young person to present behaviours
currently it doesn’t [have that capacity]. of concern. Relative to all young people,
young people in residential care are more
551. They said Child Protection workers were: likely to present with risk-taking behaviours
such as self-harm, aggressive or sexualised
constantly needing to prioritise and make behaviours, substance abuse and other
the ‘least-worse’ decision because they activities that place them, or others, at high
can’t make the best decision. risk, as a manifestation of the trauma they
have experienced.
Furthermore, young people in residential 561. In its response, Anglicare also said ‘drug
care may have developmental delays, misuse’ was not identified as a concern
experience higher incidence of poor
at Brittany’s Care Team meetings or in
mental health, disability, emotional and
behavioural difficulties than other young her Safety Plans, and her Care Team and
people and are at greater risk of contact Child Protection did not identify a need for
with services such as Police and the youth treatment.
justice system. Additionally, for Aboriginal
young people there is the added impact 562. The investigation notes the Residential
of discrimination, intergenerational Care Program Requirements state:
trauma and disconnection from culture.
All children in residential care with
557. Child Protection’s policy frameworks rely substance abuse issues must be referred
on Care Teams and plans to manage risks to a drug and alcohol treatment service.
CSOs will ensure Care Teams explore any
to children and coordinate responses.
substance abuse issues and co-ordinate
558. However, the evidence from the five cases an appropriate response in line with case
plan goals for the child.
in this report shows there was sometimes
confusion between Child Protection and 563. In some cases in this report, documented
CSOs about who was meant to lead Care plans for children quickly became out of
Teams or planning. date due to their escalating behaviours.
559. There were also multiple examples of 564. The Child Protection Principal Practitioner
CSOs failing to engage services to address said at interview that for children such as
children’s needs and behaviours. For Avery and Brittany:
example:
… the horse has almost bolted so to speak
• CAFS did not ensure counselling for in terms of the intensity of each day,
Quinn for two years despite her history particularly as their behaviours escalate
meaning everyone is scrambling to
and experiences in residential care.
address the crisis of the day.
• Avery’s mother highlighted that
her daughter needed therapeutic 565. They said Child Protection recently
treatment. However, even in appointed new ‘Practice Leaders’ to work
therapeutic residential care units, on case planning to try to have a ‘growing
clinicians still do not provide direct impact in that space’.
support to children, but rather provide
566. Berry Street’s response to the draft report
advice to staff about trauma-informed
stressed:
care.
The education, health, disability and
• Uniting, Berry Street and Anglicare
justice systems all play a pivotal and
failed to arrange drug and alcohol interconnected role in protecting and
referrals or services for Kylie and caring for children in out-of-home care
Brittany, despite evidence they and, arguably, all could have done more
were using illegal drugs or misusing to support the five children whose
experiences are examined in the Report.
prescription medication.
560. In response to the draft report, Berry 567. Health researchers argue that workers
Street did not agree Brittany’s misuse need better support to meet the health
of prescription medication should be needs of those in care because ‘the system
characterised as a substance abuse issue lets people down’ and ‘young people’s
and stated there was no evidence that she experience of care does not align with the
would benefit from drug treatment. definition of care’ (Smales et al, 2020).

Incident reporting 574. In response to the draft report, the Chief
Commissioner of Police accepted there
568. The five cases also demonstrate ongoing
was a number of incidents noted by the
challenges with Child Protection’s incident
investigation where reports of alleged
report and response system.
offences were not recorded or followed up
569. The five children in this report had multiple by Police. He referenced multiple policies
incidents that required an incident report, that provide ‘clear direction’ for Police to
including alleged assaults and absconding. record all reported incidents.
The CSOs complied with incident report
575. As such, the Chief Commissioner
requirements in some cases but, in others,
noted the investigation had highlighted
there is evidence that workers:
some potential areas for ‘Police service
• failed to complete incident reports improvement’ and further collaboration
with other agencies. He stated:
• incorrectly categorised incidents as
‘non-major’ Victoria Police acknowledges its role in
working collaboratively with our partners
• failed to notify Police of possible
to address and minimise harm and risk
offences against children. for vulnerable children, including those
in residential care. Considering findings
570. Appendix 2 compares CSOs’ compliance from the Royal Commission into Family
with incident reporting requirements for Violence and Royal Commission into
the main incidents described in this report. Institutional Responses to Child Sexual
Abuse, we have commenced a program
571. The Department identified and corrected of work to strengthen our responses to
these problems in some cases, but not all. children, and particularly in care. This
has included enhanced training and
572. The investigation observed there is also communication to our specialist units,
confusion about what constitutes a ‘report’ to better protect children, including
recognition of the importance of third-
to Police. At times, CSOs seem to have
party reporting.
conflated a Police report with a formal
victim statement – while the latter must 576. The Chief Commissioner also
be made by the victim, anyone can make a provided further information about
Police report. Police investigations and these have
been included in the report where
573. There were also issues with the way
relevant. Appendix 1 sets out the Chief
contact between Police and agencies
Commissioner’s response.
was documented. In the cases of Kylie,
Brittany and Alex, there were occasions 577. CSOs gave evidence that the Department’s
where CSOs provided evidence that incident reporting requirements are
workers notified Police about incidents, unclear; feedback from the Department
but Police had no record of this contact. on reports is inconsistent; and only limited
While sometimes the Department and training was offered when the new critical
CSO records lacked sufficient detail about incident management system was rolled
the Police contact to investigate further, out, primarily in Melbourne.
it is clear that collaboration between the
agencies can be improved to resolve these 578. The Incident reporting policy update,
issues. effective 3 February 2020, provides some
clarity. Major and non-major incident
reports are now to be submitted within
three days and there are clear categories
of major incidents that must be internally
investigated.
Cultural support and planning for Medication and chemical restraint
Aboriginal children
584. Three of the five children in this report –
579. In Kylie’s case, Child Protection and Quinn, Avery and Alex – had evidence in
two of the CSOs failed to meet some of their files suggesting they may have been
the requirements designed to support medicated to manage or control their
Aboriginal children’s connection to culture behaviour.
and community. Some of these issues were
not addressed until Kylie moved to VACCA, 585. Avery’s mother also told the investigation
an Aboriginal Community Controlled that, because Avery is being prescribed a
Organisation. drug as a chemical restraint, specialised
disability carers Avery’s mother engaged
580. At interview, the VACCA representative are not permitted to work with Avery
said the failures in Kylie’s case are not in the home. She said this means Avery
isolated. They expressed frustration that remains in residential care.
plans are often delayed and do not seem
to be a priority for Aboriginal children. 586. Use of possible ‘chemical restraints’ carries
human rights implications. In the disability
581. This view is supported by other sector, it is subject to regulation and
complaints to the Ombudsman. During oversight to protect the rights of people
the investigation, another Aboriginal with disabilities. Registered disability
girl approached the Ombudsman with providers must obtain authorisation from
concerns about her treatment in residential the Department before using chemical
care. When investigators looked at her restraints.
case, they found she went into out-of-
home care in August 2017 but was not 587. The investigation identified no such laws
given an endorsed cultural plan until or protections for children in residential
November 2019, more than two years later. care. In the three cases in this report, Child
Protection and the CSOs investigated
582. CCYP’s 2015 report on residential care, “… could not be sure if the children were given
as a good parent would…”, also found that medication for this purpose.
the ‘current residential care system can
contribute to the isolation of Aboriginal LGBTIQ support
children from their culture and community’.
588. Two of the five children in this report –
583. The investigation notes that in the 2018-19 Quinn and Alex – experienced problems
State budget, the Victorian Government in residential care because of their gender
allocated $11.9 million over four years identity.
for a new cultural planning model. The
589. The investigation acknowledges Quinn
initiative is part of the implementation of
was in residential care some 10 years
Wungurilwil Gapgapduir, a partnership
ago. CAFS says it has since developed
between the Aboriginal community,
more inclusive practices. It is undergoing
Government and CSOs, which aims to
‘Rainbow Tick Standards’ accreditation and
ensure Aboriginal children and young
employed an Inclusion and Diversity Lead
people in out-of-home care are ‘better
in 2019.
connected to culture, country and
community’. 590. Alex’s more recent experience in 2019,
when he was placed in a unit with children
who were likely to target him, suggests
there is still room for improvement.

591. The investigation did not hear evidence 597. A VACCA representative also said:
about the experiences of other LGBTIQ
The complexity of our young people is
children in residential care. However, so challenging and individualised, that
it notes that during the period under to ever imagine you can get four young
investigation, there was little written persons, other than a sibling group, that
guidance for Child Protection or CSO could just live alongside each other, is a
workers about how to support LGBTIQ bit of a pipe dream in my opinion. I think
four bed units in and of itself is a quite
children.
unrealistic demand … four young people
living together with all their complex
Potential solutions needs, with all their trauma.
592. The investigation explored two potential 598. Children with lived experience of
solutions to part of the problems identified residential care sometimes voice similar
in evidence: concerns. The Institute of Child Protection
Studies ‘Safe and sound’ report quoted
• a new two-bed residential care model one child who said:
• an independent advocate to promote You have to think about - instead of
the rights of children in care. just slapping three random people in a
house together and hoping for the best.
A two-bed residential care model Because that’s either going to work out
really well or blow up in your face.
The need for change
599. Quinn also highlighted the risks in her
593. Multiple witnesses agreed that the State interview with the investigation:
Government needs to move away from the
current four-bed model of residential care. They can’t just randomly mix different
backgrounds together that are not
594. Seventy per cent of current standard and compatible, like, they all have problems
therapeutic residential care units have but they’re different types of problems
that will clash … the good kids who come
been built to house up to four children.
from bad family backgrounds, they’ll get
mixed in with the kid that is bad and the
595. The investigation heard the four-bed
bad kid turns the good kid into being bad,
model is not in the best interests of because … the bad kids terrorise the good
children with such complex histories and kids and that psychologically drives them
needs. The Department advised that insane, then the good kids become bad
while demand for residential care services kids also and it’s a cycle.
is increasing, the number of beds has
600. An investigator employed by one of the
remained the same, making placement
CSOs raised similar concerns. They said
matching even more challenging.
‘housing some young people together
596. A Berry Street representative said at … can create an increase in criminal
interview: activity’ by the children; and there is
little workers can do to prevent children
It just seems incredibly flawed to put from absconding from care and putting
four children with complex behaviours
together. With the best matching in the
themselves at risk.
world, things will still happen.
601. Psychologists use the term ‘social Alternative models of residential
contagion’ to describe this effect. care
According to this theory, when people
The investigation learned of some existing
are exposed to behaviours such as
alternative models of residential care that try
aggression or self-harm by others, they
to meet the needs of children better.
may imitate that behaviour. This kind of
mimicking behaviour can be particularly Anglicare’s Keep Embracing Your Success
common for adolescents or children (KEYS) trial
with development disorders such as
autism spectrum disorders. KEYS is a Department-funded three-year
trial of two single-sex residential care units.
602. During the investigation, the The units provide specialist mental health
Department acknowledged the and community supports to children,
placement in one house of four including ‘assertive outreach’ with the
unrelated children, with adverse life children and their families once the person
experiences, trauma and behaviours leaves the program. The cost of a KEYS unit
of concerns, ‘may result in a high level is $2.38 million, nearly double the cost of a
of incidents that impact on children’s standard residential care unit. It uses a four-
safety, their exposure to further trauma bed unit model.
and the quality of care they receive’:
Berry Street’s Teaching Family Model (TFM)
Due to the current four residential program
care four-bed model, it is not possible
to place highly complex children Berry Street’s TFM program provides
that require a high staff-to-child residential care in four-bed units with a focus
ratio staffing model and so many on interpersonal and living skills and working
children are subsequently placed in
closely with families to help children build
contingency units when they may
have been accommodated in two bed healthy family relationships. The program is
units. designed for six-year-olds to 17-year-olds.
It is already offered as a form of specialised
603. The last statement refers to children residential care in New Zealand.
needing to be placed into short-term
units, because their needs cannot be Mackillop Family Services
met in the four-bed model. This results Mackillop, another CSO, manages three
in frequent movements and placement residential care homes where children are
instability for children. The Department supported by ‘professional foster carers’,
acknowledged that some children supplemented by 25-30 hours of funded
experienced over 20 placements in out- in-home support.
of-home care during 2018-19 and 2019-
20. The four children in this report who The Department said:
are still in residential care had moved
the model works very well when there are
between five and 13 times over one to committed carers; but when carers leave
two years. the program after several years, recruitment
of new foster carers for the program can be
difficult. There is no current plan to expand
these services.

The proposed two-bed residential care model 608. The Department estimated it would cost:
604. The Department has been considering the • $1.2 million a year to operate a two-
benefits of moving the residential care bed unit. This includes a 0.6 full-time
system from a four-bed model to a two- equivalent clinical specialist to offer
bed model. more specialised care to children. That
means each unit would operate like a
605. The Department provided a summary of therapeutic residential care unit
its business case to the investigation. It
said this model would provide capacity for • $1.2 million a year to operate a
individualised and intensive responses to standard four-bed unit under the
children, with the support of mental health current model
clinicians, family workers and community • $1.6 million a year to operate a
workers. It also said it would provide for therapeutic four-bed unit under the
better matching of children in placements, current model.
stability and a sense of belonging for
children, and more opportunities to 609. The Department said the two-bed model
engage with family, community and would require extra residential care
education: workers and there would be some capital
costs associated with implementation.
[P]otential benefits lie in the ability to
tailor responses to a smaller number of 610. The Department also noted the residential
[children] by eliminating the combined care system would still need to maintain
impact of four young people with a range some larger homes so children from the
of trauma related complexities. Young
same family can live together in care.
people in residential care often talk about
the disruptive impact of other more
611. The investigation considers that the two-
complex young people on their sense of
safety and stability. bed model is a fundamental change to the
way residential care is provided.
606. The business case identified savings in a
two-bed model. It noted the Department 612. The Department said:
is spending a significant amount of The ability to release or invest in system
money supporting children in short-term capacity to enable a more tailored or
temporary arrangements because they individualised intensive response for a
cannot be placed in residential care units. small proportion of highly vulnerable
young people would assist in providing
These children have highly complex needs
the flexibility needed within the current
that require high staff-to-child support that system and reduce the need for more
cannot be met in the four-bed model. expensive emergency placements in
contingency arrangements.
607. The Department said the draft costs of
a two-bed model are about $285 million 613. CCYP supported a two-bed model in
a year. The State Government budgeted its 2019 report, ‘In our own words’. It
$161 million for residential care demand recommended:
in 2019-20. These figures do not include
more flexible placement options, including
the temporary placement arrangements two bed or single bed placements
funded outside of this budget. with tailored and appropriately skilled
staff (not through current contingency
arrangements).
614. Berry Street’s response to the draft 619. The Department and the CSOs have
report commended the Ombudsman for internal complaints systems available
supporting the transition to a two-bed for children and families. In these cases,
model as part of the solution to current the systems were not effective ways to
problems in the system. It said this model promote the children’s interests.
will not solve the systemic issues on its
own. It said there also needed to be: 620. Victoria also has two external bodies
with an oversight role - CCYP and the
• professionalised therapeutic foster Ombudsman.
care models
621. CCYP is Victoria’s specialist body
• better access to health and education for children and young people. It is
• Targeted Care Packages that enable independent of the Department and
children to get support and treatment can investigate systemic issues in the
in their home environments, and child protection system and recommend
flexible shared care models with improvements. It also oversees children’s
families. services and advocates for best practice.
However, it is not currently set up to act as
615. Berry Street said other reforms to the an advocate for individual children or their
child protection system could save families.
money, which could be used to fund
these reforms. It noted its recent report 622. The Ombudsman takes complaints
on early intervention programs shows about public and publicly funded bodies,
these programs have the potential to save including the Department and CSOs. It
Victoria $1.6 billion over the next 10 years. is constitutionally independent and can
resolve or investigate complaints from
An independent advocate for children in individual children and their families.
care However, as CCYP noted in its 2019 report,
‘In our own words’, children may not know
616. The investigation also considered practical
how to complain. Of the five complaints in
ways to protect the rights and interests of
this report, only one came from the child;
children in residential care before problems
and that child, Quinn, is now an adult.
occur.
The other four complaints were made by
617. The Children, Youth and Families Act concerned family and friends.
already requires Child Protection and CSOs
623. These arrangements lack an independent
to consider the child’s views and wishes
person who regularly visits individual
when determining a child’s best interests
children in care and advocates on their
(section 10(3)(d). In Victoria, Child Safe
behalf.
Standards also say children:
have a right to be heard and have their
624. Such offices exist in other contexts. South
concerns and ideas taken seriously, Australia’s Office of the Guardian for
particularly on matters that affect them – Children and Young People advocates
including how to keep them safe. for the rights of children in care in that
state. In Victoria, the Office of the Public
618. In these five cases, the children’s files and
Advocate plays a similar advocacy role for
other evidence shows the children or their
people with a disability.
families often voiced early concerns with
Child Protection or CSO workers, but with
little success.

Advocacy models
South Australian Guardian for Children and Victorian Public Advocate
Young People
Victoria’s Public Advocate has statutory
South Australia has a statutory Office of the powers to promote and safeguard the rights
Guardian for Children and Young People to and interests of people with a disability. The
advocate for the rights of children in care. Public Advocate:
The Guardian’s staff:
• advocates for people with a disability
• visit children and young people in on a systemic and individual basis
residential care units
• operates a ‘community visitor’ program
• talk to children and observe their under which volunteers visit mental
situations, and speak with carers health facilities, supported residential
• advocate for individual children and services and disability accommodation.
promote their best interests. They can
Community visitors can raise concerns with
address issues with care providers
facilities and the Department of Health
directly and report to the responsible
and Human Services. They can also bring
minister or refer matters to other
cases of abuse and neglect to the Public
agencies
Advocate’s attention.
• inquire into and provide advice to the
Minister about systemic shortfalls in The Public Advocate can lodge complaints
services. or refer matters to the Ombudsman for
consideration and investigation.
The Guardian is separate from the South
Australian Commissioner for Children and
Young People. Both the Guardian and
Commissioner can lodge complaints on
behalf of children and young people with the
Ombudsman.
625. Berry Street told the investigation 629. CCYP’s 2019 report recommended a
it supported the introduction of an ‘specialised independent complaints body’
independent children’s advocate in to ensure ‘children and young people feel
Victoria, although it said this needed to ‘sit confident to speak about their experiences
alongside significant reform of the child and care’. CCYP could work with other
and family services system’. bodies to advocate for children and
resolve concerns where possible. It could
626. In Victoria, the advocacy function could be lodge complaints on behalf of children and
assigned to an existing oversight agency young people with independent offices,
or, as is the case in South Australia, it could such as the Ombudsman, where needed.
be established as a stand-alone agency. Such a system would close the current gap
The advocate function aligns with CCYP’s in Victoria’s oversight.
role as the specialist body for children
and young people and with the CCYP’s
existing statutory objective of promoting
improvement to out-of-home care services
for children.
627. When consulted during the investigation,

CCYP said:
establishing the [advocacy] function
within the CCYP would avoid the risk of
duplication between two bodies, make use
of the CCYP’s knowledge of the out-of-
home care system and create efficiency.
628. CCYP also said:

While adding the advocate function to
the CCYP’s current roles would require
internal separation of the individual
advocacy function from the body’s
systemic and inquiry activities, this is
not unusual within a statutory body.
The CCYP currently manages diverse
functions including inquiry, oversight and
regulatory functions. A further benefit of
locating an individual advocate function
within the CCYP is that the information
obtained from working with individual
children in care could inform the CCYP’s
system oversight activities.

Conclusions
630. Residential care is meant to provide a safe 638. Supervision in some cases was inadequate.
place for children who cannot live safely Berry Street workers caring for Alex
at home. In the case of these five children, allowed one of the other boys in his
that system failed. unit to sleep in Alex’s room overnight. A
Berry Street representative maintained
631. The evidence records assaults or alleged at interview that staff checked the boys
assaults against all five children while they regularly and ‘we can’t force young
were in residential care. people out of [an]other’s bedroom’. A
632. It shows the behaviour of the children departmental representative noted workers
grew worse after they went into care. could have called for back-up or taken Alex
Quinn’s behaviour reportedly became from his room to ensure his safety.
more aggressive. Kylie and Brittany began 639. Kylie, Brittany and Avery all absconded
using illegal drugs and running away. Alex from residential care multiple times
became involved in criminal offending and before reporting they had been raped by
started using more drugs. adult men in the community. Staff were
633. The evidence shows Child Protection and sometimes unclear about the children’s
the CSOs knew there were risks involved safety plans, which are meant to be
in the placements of these children, either implemented when a child does not return
before they moved in or soon afterwards. to their unit. The steps taken by workers
to locate the children and report them as
634. Quinn and Alex were placed with missing varied.
other children with histories or risks of
aggression or sexualised behaviour. Kylie, 640. CSOs sometimes lacked critical information
Brittany and Alex were placed with children about the children to assist workers in
with histories of drug use or criminal providing informed care and support.
offending or sexual exploitation risks. Avery 641. The investigation also identified examples
had other children introduced into her unit, of other problems with the children’s care:
despite early agreement she needed to live
alone with dedicated workers. • failure to lodge incident reports or
notify Police of possible criminal
635. The investigation found these problems were offences against the children
not the result of deliberate disregard for the
welfare and safety of the children. In some • potential use of medication as a
cases, the CSOs expressed concerns about chemical restraint, without reporting or
the suitability of proposed placements. oversight
However, they told the investigation they • inadequate support for Kylie, a young
could not always resist ‘pressure’ from Child Aboriginal woman, to maintain her
Protection to take the children. connection with her culture and family
636. Child Protection representatives and the • inadequate support for transgender
Department spoke of a stretched system and non-binary children in care.
in which Child Protection workers are 642. The problems experienced by these
forced to make ‘least-worse’ decisions five children are not isolated. This is the
for children. Placement decisions were latest of many reports to highlight such
dictated by the availability of beds, rather problems in the residential care system.
than children’s best interests. CCYP identified similar concerns in its 2015
report and again in a 2019 report. Little
637. In some cases, the CSOs’ care and appears to have changed.
supervision of the five children also fell short
of what a good parent would expect their
child to experience in State-funded care.
643. Nearly 1,000 Victorian children lived in 650. It is also important that the voices of
residential care at some time during 2019- children in residential care matter and that
20. They all have a right to be protected. these are included in policies and practice.
644. In response to the draft report, Berry 651. In response to the draft report on 25 May
Street said these children’s stories: 2020, the Secretary of the Department
stated:
show that the current child and family
services system, as a whole, is not The experiences of the five young people,
designed to operate in the children’s best as detailed in your report, are concerning.
interests and allow them to thrive. The Department and Community Service
Organisations are committed to reform
645. Berry Street stressed there needed to be the residential care system to provide
a major transformation of the child and intensive support and stabilisation for
family services system to ensure families young people with complex needs, and
can get help earlier in the community and to support their transition to family based
care and independence.
address their issues without continual
involvement of statutory Child Protection 652. On 21 October 2020, after reviewing the
services. final draft report, the Minister for Child
Protection responded on behalf of the
646. In response to the draft report, Alex’s
Victorian Government and accepted all of
relative commented on the investigation:
the recommendations made to Ministers.
To protect children and to take steps to The Minister noted policy and budget
ensure the most vulnerable ones receive would need to be examined to develop
the proper duty of care they deserve
and implement some of the proposed
gives me hope in a system I had become
very disillusioned with. solutions. He also commented that the
report:
647. This investigation considered two possible
highlights a range of issues that
solutions. contributed to an unsatisfactory level
of care and safety for some of Victoria’s
648. The first is a transition from a four-bed
most vulnerable children. ...
model of residential care to a two-bed
model, as set out in the previous section. As an immediate action the Department
The investigation heard children in will reinforce to all staff and Community
Service Organisations the importance
residential care have increasingly complex
of reporting allegations of physical
needs and behaviours that makes it hard and sexual abuse of children to the
to ‘match’ four children in the same unit. Department and to Victoria Police.
Evidence from the Department, CSOs and
children with lived experience of care all 653. The Minister’s full response is provided on
said it was becoming impossible to place page 88.
children safely in the current system.
654. After reviewing the final draft report
649. The second is an independent advocate and having an opportunity to consider
to protect and promote the rights of the proposed solutions, the Secretary
children in residential care. Complaints and accepted all of the Ombudsman’s
systemic oversight bodies play a valuable recommendations, noting some require
role. But these cases highlight the need for budgetary and policy consideration.
an independent person who can work with The Secretary’s full response is provided
individual children and families, and Child on page 90.
Protection and CSOs to protect children’s
interests before problems occur.
conclusions 83
Opinion
655. Based on the evidence obtained during the investigation, the Ombudsman has formed the
following opinions pursuant to section 23(1)(g) of the Ombudsman Act:
Quinn
Child Protection and CAFS acted in a manner that was wrong and inconsistent with the best
interests of the child under section 17(2) of the Charter of Human Rights and Responsibilities
Act, in:
• placing Quinn in a unit with another child with a known history of assaults, without taking
adequate steps to manage the risk
• maintaining Quinn’s and the other child’s placement in the unit for two years, despite
violent incidents between the two children
• failing to ensure incident and Police reporting in response to Quinn’s allegations of sexual
assault.
Kylie
Child Protection and Uniting acted in a manner that was wrong and inconsistent with the best
interests of the child under section 17(2) of the Charter of Human Rights and Responsibilities
Act, in:
• failing to submit an incident report and notify Police regarding Kylie’s alleged ‘bashing’ by
another child in the unit
• failing to submit incident reports regarding three alleged sexual assaults of Kylie by
another child in the unit
• not referring Kylie for drug and alcohol assessment and/or treatment.
Child Protection and Berry Street acted in a manner that was wrong, and inconsistent with
the best interests of the children under section 17(2) of the Charter of Human Rights and
Responsibilities Act, in:
• placing another child in Kylie’s unit despite an assessment that this involved medium to
high risks for all of the children.
Child Protection acted in a manner that was wrong and inconsistent with the best interests of
the children under section 17(2) of the Charter of Human Rights and Responsibilities Act, in:
• failing to develop for Kylie an endorsed cultural plan until after she had been in care for
53 weeks.
Brittany
Child Protection and Anglicare acted in a manner that was wrong, and inconsistent with
the best interests of the child under section 17(2) of the Charter of Human Rights and
• placing another child with Brittany when risks to Brittany were identified, without taking
adequate steps to manage the risk.
Child Protection, Berry Street and Anglicare acted in a manner that was wrong and
inconsistent with the best interests of the child under section 17(2) of the Charter of Human
Rights and Responsibilities Act, in:
• not referring Brittany for drug and alcohol assessment and/or treatment.
Avery
Child Protection and Berry Street acted in a manner that was wrong and inconsistent with
• placing additional children in Avery’s unit despite evidence she required dedicated care
• not ensuring alleged physical assaults by another child were reported to Police, and not
ensuring an incident report was generated for one of the alleged assaults
• not referring Avery for drug and alcohol assessment and/or treatment.
Alex
Child Protection and Berry Street acted in a manner that was wrong and inconsistent with
• placing Alex in a unit with three other boys, without taking adequate steps to manage the
risk or sharing information relevant to the risk.
Child Protection and Junction acted in a manner that was wrong and inconsistent with
• maintaining Alex’s placement with another child despite evidence of the negative impact
on Alex’s behaviour
• not reporting the alleged assault by a worker to Police.
conclusions 85
Recommendations
Pursuant to section 23(2) of the Ombudsman Act, it is recommended that:
To the Minister for Child Protection and To the Minister for Child Protection
Minister for Mental Health
Recommendation 3
Recommendation 1
Consider establishing an independent
Commence conversion of standard four- children’s advocacy function within the
bed residential care units to therapeutic CCYP to enable it to:
two-bed units with enhanced access
for the children to services, particularly • participate in placement decision-
mental health and education, while making for residential care, to
maintaining some capacity in the system prevent unsafe decision making
for larger groups (ie siblings). • promote the rights of children
to participate in decisions about
Response placement, service-delivery and
Accepted by the Minister for incident investigations that affect
Child Protection on behalf of the them
Government. See the Minister’s • support or represent children to
full response on page 88. make complaints about their care
• make representations on behalf of
To the Minister for Child Protection children identified as high risk
and the Minister for Health • refer serious concerns to
independent complaint handling and
Recommendation 2 investigative oversight bodies such
Implement a state-wide medication as the Victorian Ombudsman
management policy for children in • regularly visit and inspect residential
residential care that includes minimum care settings
standards and regulation for the
• publicly report on its activities and
prescription, administration and
outcomes.
notification of chemical restraints to
children. Response
This should be supported by: Accepted.
• mandatory training for residential
care workers
• updates to the Residential Care
Program Requirements and Child
Protection Manual
• guidance to medical practitioners.
Response
Accepted.
To the Department of Health and Human
Services
Recommendation 4 Recommendation 5
Within 90 days, undertake the following In consultation with Victoria Police and
actions for each child to address the CSOs providing out-of-home care, review
deficits in care identified in the report: the Protocol between Department of
[Health and] Human Services – Child
• for current clients, conduct a review
Protection and Victoria Police (2012)
by a Principal Practitioner of the
and the Addendum: Preventing sexual
existing placement to confirm that
exploitation of children and young people
it is safe and appropriate to meet
in out-of-home care (2014) to ensure all
the child’s needs, and that the
allegations of physical and sexual assaults
child’s views have been taken into
of children in residential care are:
consideration
• ensure reports are made to Police • reported to Victoria Police,
for all allegations of assault regardless of whether the victim
wants to make a statement
• with the child’s consent, engage
specialist therapeutic services such • recorded in the systems of Victoria
as sexual assault counselling to Police and the reporting agency.
support their recovery from trauma
Response
• confirm the child’s eligibility, and
make referrals for support, from Accepted by the Minister for Child
Victims of Crime, the Redress Protection, the Chief Commissioner of
Scheme and independent legal Police and the Department Secretary.
services for advice about their
rights and care.
Response
Accepted. See the Department

Secretary’s full response at page 90.
recommendations 87
Minister’s response to the final report
responses 89
Department Secretary’s response to the draft report
responses 91
Appendix 1: CSO and Victoria Police
responses
appendix 1 93
appendix 1 95
appendix 1 97
appendix 1 99
appendix 1 101
appendix 1 103
appendix 1 105
Appendix 2: Incident reporting
Quinn
Incident CSO Incident Correct Report to CSO states Report

report type & DHHS 24 Police on Police
impact on hours contacted system
report
Physical assault by CAFS

other child in care
4 4 4 4 4
Alleged sexual CAFS
assaults by other
4 7 4 7 7
child in care
Kylie

report
Alleged sexual assault Uniting N/A N/A

by other child in 7 4 4
care – inappropriate
touching
Alleged sexual assault Uniting N/A

by other child in 7 4 7 4
touching
Alleged sexual Uniting N/A

assault other child in 7 7 7 4
touching
Alleged rape by Uniting

person in community
4 4 4 4 4
Alleged physical Uniting N/A
assault by other child 7 4 7 7
Alleged physical Berry
assault by person in Street
4 4 4 4 7
community
Alleged physical VACCA N/A N/A

assaults by other 7 7 7
resident
Brittany

report
Absconding and Berry

threats of suicide Street
4 4 4 4 4
Absconding and Berry N/A N/A N/A
threats of suicide Street
4 4
Absconding and Berry N/A
report overdose Street
4 4 4 4
of prescription
medication
Alleged sexual assault Berry
by other resident - Street
4 7 4 4 7
kissing
Alleged rape by Anglicare
person in community
4 4 4 4 4
Absconding with Anglicare N/A
other resident
4 4 4 4
(only 1) (only 1) About
explicit
texts from
adult males
Alleged rape by Anglicare

people in community
4 4 4 4 4
Avery

report
Alleged assault by Berry

agency worker Street
4 7 7 4 4
Alleged rape by person Berry
in the community Street
4 4 4 4 4
Alleged physical Berry
47 4 N/A 4 N/A
assaults by other Street
777 777
resident 4 7 7
Suspected overdose Berry N/A N/A
of prescription Street
4 7 7
medication
Access to ‘locked’ Berry N/A N/A

medication at unit Street
4 4 4
appendix 2 107
Alex

report
Alleged rape by other Berry

child Street
4 4 4 4 4
Alleged physical Junction
assault by person in
4 7 7 4 7
community
Alleged assault by Junction

worker
4 4 4 4 7
Source: Victorian Ombudsman (incorporating information from Department of Health and Human Services and CSOs)
appendix 2 109
Victorian Ombudsman’s Parliamentary Reports tabled since
April 2014
2020 2019
Investigation into corporate credit card misuse Investigation of matters referred from the
at Warrnambool City Council Legislative Assembly on 8 August 2018
October 2020 December 2019
Investigation into review of parking fines by the WorkSafe 2: Follow-up investigation into the
City of Melbourne. management of complex workers compensation
September 2020 claims
December 2019
Investigation into the planning and delivery of
the Western Highway duplication project Investigation into improper conduct by a
July 2020 Council employee at the Mildura Cemetery
Trust
Ombudsman’s recommendations – third report
November 2019
June 2020
Revisiting councils and complaints
Investigations into allegations of nepotism in
October 2019
government schools
May 2020 OPCAT in Victoria: A thematic investigation
of practices related to solitary confinement of
Investigation of alleged improper conduct by children and young people
Executive Officers at Ballarat City Council
September 2019
May 2020
Investigation into Wellington Shire Council’s
Investigation into three councils’ outsourcing of handling of Ninety Mile Beach subdivisions
parking fine internal reviews
August 2019
February 2020
Investigation into State Trustees
June 2019
Investigation of a complaint about Ambulance

Victoria
May 2019
Fines Victoria complaints

April 2019
VicRoads complaints
February 2019
2018 2017
Investigation into the imprisonment of a Investigation into the financial support

woman found unfit to stand trial provided to kinship carers
October 2018 December 2017
Investigation into allegations of improper Implementing OPCAT in Victoria: report and

conduct by officers at Goulburn Murray Water inspection of the Dame Phyllis Frost Centre
October 2018 November 2017
Investigation of three protected disclosure Investigation into the management of

complaints regarding Bendigo South East maintenance claims against public housing
College tenants
September 2018 October 2017
Investigation of allegations referred by Investigation into the management and

Parliament’s Legal and Social Issues protection of disability group home residents
Committee, arising from its inquiry into youth by the Department of Health and Human
justice centres in Victoria Services and Autism Plus
September 2018 September 2017
Complaints to the Ombudsman: resolving them Enquiry into the provision of alcohol and drug
early rehabilitation services following contact with
July 2018 the criminal justice system
September 2017
Ombudsman’s recommendations – second
report Investigation into Victorian government school
July 2018 expulsions
August 2017
Investigation into child sex offender Robert
Whitehead’s involvement with Puffing Billy and Report into allegations of conflict of interest
other railway bodies of an officer at the Metropolitan Fire and
June 2018 Emergency Services Board
June 2017
Investigation into the administration of the
Fairness Fund for taxi and hire car licence Apologies
holders April 2017
June 2018
Investigation into allegations of improper
Investigation into Maribyrnong City Council’s conduct by officers at the Mount Buller and
internal review practices for disability parking Mount Stirling Resort Management Board
infringements March 2017
April 2018
Report on youth justice facilities at the
Investigation into Wodonga City Council’s Grevillea unit of Barwon Prison, Malmsbury and
overcharging of a waste management levy Parkville
April 2018 February 2017
Investigation of a matter referred from the Investigation into the Registry of Births, Deaths
Legislative Council on 25 November 2015 and Marriages’ handling of a complaint
March 2018 January 2017
victorian ombudsman parliamentary reports 111

Victorian Ombudsman’s Parliamentary Reports tabled since
April 2014
2016 2015
Investigation into the transparency of local Reporting and investigation of allegations

government decision making of abuse in the disability sector: Phase 2 –
December 2016 incident reporting
December 2015
Ombudsman enquiries: Resolving complaints
informally Investigation of a protected disclosure
October 2016 complaint regarding allegations of improper
conduct by councillors associated with political
Investigation into the management of complex donations
workers compensation claims and WorkSafe November 2015
oversight
September 2016 Investigation into the rehabilitation and
reintegration of prisoners in Victoria
Report on recommendations September 2015
June 2016
Conflict of interest by an Executive Officer in
Investigation into Casey City Council’s Special the Department of Education and Training
Charge Scheme for Market Lane September 2015
June 2016
Reporting and investigation of allegations
Investigation into the misuse of council of abuse in the disability sector: Phase 1 –
resources the effectiveness of statutory oversight
June 2016 June 2015
Investigation into public transport fare evasion Investigation into allegations of improper
enforcement conduct by officers of VicRoads
May 2016 June 2015
Investigation into Department of Health

oversight of Mentone Gardens, a Supported
Residential Service
April 2015
Councils and complaints – A report on current

practice and issues
February 2015
Investigation into an incident of alleged

excessive force used by authorised officers
February 2015
2014
Investigation following concerns raised by

Community Visitors about a mental health
facility
October 2014
Investigation into allegations of improper

conduct in the Office of Living Victoria
August 2014
victorian ombudsman parliamentary reports 113

Victorian Ombudsman
Level 2, 570 Bourke Street
Melbourne VIC 3000
Phone 03 9613 6222

Email complaints@ombudsman.vic.gov.au
www.ombudsman.vic.gov.au

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Investigation into complaints about assaults of five children

living in Child Protection residential care units

The Honourable the President of the Legislative Council

The Honourable the Speaker of the Legislative Assembly

Deborah Glass OBE

Child protection and residential care 20

The children’s experiences 29

Wider problems and potential solutions 71

Appendix 1: CSO and Victoria Police

Appendix 2: Incident reporting 106

5. The complaints all raised questions about

The evidence shows:

41. The Department and the CSOs have

46. The Minister also commented on the

47. In May 2020, after reviewing the draft

48. After reviewing the final draft report

55. The complaints all raised questions about

68. The people who complained to the

• Human services standards evidence • examined relevant CSO policies

child protection and residential care 21

Figure 1: Example of a residential care placement process

Child Protection decides Child Protection makes Court makes

child protection and residential care 23

Year Foster Kinship Permanent Residential Totals

2019-20 1,660 7,126 2,963 433 12,182

2018-19 1,697 6,399 2,810 453 11,363

2017-18 1,673 5,581 2,625 424 10,305

2016-17 1,560 5,043 2,407 424 9,446

child protection and residential care 25

child protection and residential care 27

150. The Department’s Incident reporting

• Report all incidents that result in harm

151. During the period investigated all major

Figure 4: Quinn’s timeline of key events

CAFS Foster Care x 2 CAFS residential

Only child in foster

1999 2005 2018 2006 2008 2009 2010 2019 2011

Report to Child Children’s Court makes Disclosure of sexual abuse

the children’s experiences 29

160. The evidence confirmed there were many

170. Quinn’s records also noted she would need

Figure 5: Records from Quinn’s file

Source: Department of Health and Human Services

the children’s experiences 31

179. The report also said Quinn ‘likes living in

180. By contrast, Quinn told the investigation

Source: Department of Health and Human Services

Alleged sexual assaults 187. In a written response to the investigation,

the children’s experiences 33

203. In 2008 when Quinn moved into the

the children’s experiences 35

Figure 7: Kylie’s timeline of key events

2018 2019 2020

Report to Children’s Alleged Alleged physical Alleged Alleged

the children’s experiences 37

Placement termination 252. Kylie stayed in Secure Welfare for 11 days

the children’s experiences 39

Figure 8: Placement Unit record of efforts to secure placement