Commission of Inquiry into Child Safety System

1. Reforming the Residential Care System: Investigate models of care and the factors contributing to the growth and reliance on a billion-dollar residential care sector, including:
   1. Analyse residential care in the historical context since the Carmody Inquiry and the increase in the use of Individual Placement Support Services and residential care.
   2. Investigate contemporary models around the world for the delivery of residential care, with a focus on best practice to support children who are more at risk.
   3. Consider what constitutes Quality of Care in both licensed and unlicensed providers, including from the perspectives of children and young people.
   4. Analyse contemporary models for licensing care providers.
   5. Investigate the current state of the market of residential care providers operating under not-for profit and for-profit models.
   6. Analyse previous Queensland government procurement and contracting process for residential care providers to identify opportunities to improve efficiency, transparency and accountability.
2. Fixing a broken system: reviewing the effectiveness of Queensland’s child safety system to keep children safe, including:
   1. The practices and procedures of the Department, specifically focussing on investigation, assessment, case work and reunification.
   2. Tertiary child protection interventions, including adoption, case management, service standards, and decision-making frameworks.
   3. The management, training, supervision, and ongoing oversight of case work within the Department.
   4. Departmental delivery structures including organisational culture; management structures and operations of regional service delivery (in each region).
   5. The ability for information sharing across relevant agencies.
   6. Review Departmental governance, including financial, procurement and contracting delegations; and structures to manage conflict of interest and reporting.
   7. Whether Departmental frontline staff are resourced and supported to do their work and outline any deficiencies in the level of support, decision-making frameworks, case loads, and court and tribunal processes.
   8. Investigate the role of the privacy provisions of the Child Protection Act 1999 and whether the provisions hamper transparency around system failures.
   9. Consider how to facilitate a culture of transparent reporting in the context of the Coaldrake Review.
   10. Investigate the role of third parties including peak bodies and oversight bodies and their interaction with the Department and Minister in pursuit of system improvement, and any issues related to funding, reporting and their role in the media to ensure integrity and accountability.
   11. Evaluate Ministerial accountability of the child safety system since the Carmody Inquiry and the role the Minister has played in the performance of the Department.
   12. Review the effectiveness of the existing Complaints Process.
3. Safer Children: failures both systemic and policy that have impeded the ability of the Department responsible for the Child Safety portfolio (the Department) to provide support to families and protection to children at risk of harm in Queensland; and in particular to use case studies to:
   1. Identify failures of the Department to intervene or to protect children, with a summary of findings and recommendations of collated coronial inquiries since the Carmody Inquiry and the establishment of the Child Death Review Board. 138 QUEENSLAND GOVERNMENT GAZETTE No. 16 [23 May 2025
   2. Review the decline in foster care and treatment of foster carers by the Department and by service providers contracted by the Department.
   3. Review Child Placement breakdowns, with a focus on cases with more than four placements in a child’s life.
   4. Investigate the contributing factors for breakdown of placements due to lack of support for kinship carers.
4. Safer Communities: Evaluate the effectiveness of the Department as a corporate parent and whether it is able to meet community expectations around parenting:
   1. Investigate through case studies children subject to dual Youth Justice and Child Protection Orders or children under the Guardianship of the Department who have committed crimes and fall within the Making Queensland Safer Laws category and determine the failures of policy, process and practice that contributed to these children choosing a life of crime.
5. Reviewing Queensland legislation about the protection of children, including the Child Protection Act 1999 and Adoption Act 2009.
6. Any other matter relevant to the inquiry.

The Commission will report on, and may make recommendations on:

1. Reforming the residential care system: which existing models of residential care best support children who have high complex needs (particularly those with a disability) and Aboriginal and Torres Strait Islander children, and appropriate market structures to best deliver those models.
2. Fixing a broken system: the implementation and appropriateness of child safety practices; Departmental structure, governance and culture; the adequacy and effectiveness of current training programs for child safety staff; the extent to which leadership structures support accountability in the protection of children; Ministerial engagement and accountability; appropriate frontline resourcing; and third parties including peak bodies and oversight bodies.
3. Fixing a broken system: design and implementation plan for a new independent complaints escalation review process to escalate serious concerns about complex cases and restore critical support for families and carers.
4. Safer children: system design to support and facilitate foster care, kinship care and adoption in a modern best practice setting.
5. Safer communities: new models of care ensuring children are provided an opportunity for intervention and rehabilitation and that escalating risk or behaviours are managed in line with community safety expectations.
6. Any reforms to ensure that Queensland’s child protection system achieves the best possible outcomes to protect children and support families.
7. Any legislative reforms required.