Child death study shows flaws in approach

By CATHERINE MASTERS

The deaths of 30 New Zealand children were examined at the international child abuse conference in Auckland yesterday.

Anne Caton, a consultant with the office of the Commissioner for Children, explained the review system of child deaths as carried out by the Children, Young Persons and Their Families Service.

The cases of all children known to the service who die are routinely reviewed, no matter what the cause of death.

This is so practice issues can be identified and improvements made.

Anne Caton studied the reviews of 30 children who died between July 1994 and July last year. She gave no details of actual cases but the cause of the deaths included homicides, accidents in the home, car accidents, drownings, fires and cot death.

"What was clear was that all of these children had the sort of disturbed, destructive and dreadful family situations that you would expect in a sample from the child protection service."

Omissions and mistakes by different workers at different times sometimes had a cumulative effect on the case, she said.

The study found many weaknesses in the investigation and assessment stage of a child's involvement with the service.

"Among the 30 cases there were eight allegations of abuse and neglect which were not followed up at all."

Four cases were closed when they should not have been and in three of those children died as a result of family homicide, Anne Caton said.

In 10 cases reviewers found the focus on the child had been lost by workers.

"In five cases the child or young person was virtually invisible.

"At the end of the review there was no picture of who was this child, what was going on with them, what was important to them, what mattered.

"The most extreme was a teenager who in 15 months' work was spoken to once by telephone."

She said that the time frame in the study followed six years of "enormous" upheaval in the service, with reports that it was not coping and was under-resourced.

"People can't possibly do professional and sensible work in these sorts of circumstances."

She said the difference between abuse which led to a death and that in which the child did not die often came down to chance.

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