Introduction to Volume 4

This volume considers the care of children who the Tasmanian Government have removed from their families of origin and placed in out of home care since 2000. This is in line with the Order establishing our Commission of Inquiry. Where we refer to children who were in care before 2000, their experiences are relevant to informing the present system.

Out of home care is provided when children cannot live with their families because of safety concerns. In most cases, these children are placed with kinship or foster carers. Placements in residential care settings are far less common.

The Government is obligated to protect children in out of home care from abuse, including sexual abuse. This is enshrined in the Children, Young Persons and Their Families Act 1997 (‘Children, Young Persons and Their Families Act’). When a child is taken into care, the Secretary for the relevant department (currently the Department for Education, Children and Young People) applies to the Magistrates Court for guardianship and/or custody to be assigned to someone who is not the child’s parent—either the Secretary of the Department or a third party—for the period of the order.1 In exercising functions and powers under the Children, Young Persons and Their Families Act, the Secretary and their delegated officers must give ‘paramount consideration’ to the ‘best interests of the child’. The State is obligated to protect these children from further harm, as well as provide them with opportunities to heal and support them to flourish.2

Unlike other groups of children receiving support from the Government, those in care live within the system and rely on government or government funded services and workers for their welfare. Children in care do not always have an advocate external to the Government (a role normally assumed by parents) who can supervise, support and protect them. Therefore, there is a heavy burden of responsibility on a statutory authority that has used the powers of the State to legally remove a child from their family of origin. Any failure to protect children from abuse in care is a significant betrayal of the trust conferred upon the State by such powers.

Children in care often, if not inevitably, have unresolved trauma from experiences of abuse or neglect that gave rise to them being taken into care. Tragically, children in care are much more likely to experience further maltreatment and exploitation, including sexual abuse, than children who are not in out of home care, and they find it more difficult to talk about their abuse and to get support for their healing and growth.

The Government has been alerted to the risk of sexual abuse for children in care several times through the findings of previous reviews of the Tasmanian statutory child protection and out of home care systems. The National Royal Commission also examined this. Throughout this volume we consider the progress that the Department for Education, Children and Young People has made towards implementing the recommendations from these reports that relate to improving the safety of children in care from sexual abuse.

A note on language

Unless otherwise stated, references to ‘the Department’ in this volume are to the Tasmanian government department responsible for out of home care. During the period under examination by our Commission of Inquiry (that is, responses to reports of child sexual abuse since 1 January 2000), this Department has been called the Department of Health and Human Services, the Department of Communities (also referred to as Communities Tasmania) and the Department for Education, Children and Young People. In October 2022, departmental responsibility for out of home care transitioned from the Department of Communities to the newly formed Department for Education, Children and Young People. When we specifically refer to the previous Department of Communities or the new Department for Education, Children and Young People, we use the full name.

As described in the glossary, the terms ‘the Child Safety Service’ or 'Child Safety Services' are used generically across our report to describe the child protection functions of the Department, including its Strong Families, Safe Kids, Advice and Referral Line.

As well as assessing and investigating notifications about children in the community, the Child Safety Service (and specifically Child Safety Officers) perform case management functions for children in out of home care.

The Child Safety Service, including out of home care services and the Strong Families, Safe Kids Advice and Referral Line, are positioned within a Directorate, which has been variously named ‘Child and Youth Services’, ‘Children and Family Services’ and, currently, ‘Services for Children and Families’. We generally refer to the variously named Directorates as Services for Children and Families.

Our Inquiry into out of home care, laid out in this volume, has shown there is much more to be done. It has concluded that Tasmania’s out of home care system lacks many of the safeguards that help protect children from sexual abuse. We heard that few mechanisms are in place to engage Aboriginal communities in decision making about their children; there are no consistently applied standards for out of home care providers; professional development and other support for staff and carers is inconsistent; and monitoring and oversight of the system, internally and externally, is inadequate. Each of these problems, alone and together, increases the risk of child sexual abuse for children in care.

We also heard that the structures and processes to respond to reports of suspected child sexual abuse (as well as other abuses of children in care)—such as the care concern process and Serious Events Review Team—have been in transition, without a clear replacement. This means there has been no guarantee that the response to child sexual abuse has been consistent or appropriate. This failure of the State is deeply concerning and must be addressed as a matter of urgency.

We have concluded that problems in protecting children from, and responding to, child sexual abuse in out of home care partly stem from a lack of strategic, expert and active executive leadership. Fundamentally, however, these failings are the result of consecutive governments’ chronic underfunding of, and failure to prioritise, out of home care and the statutory child protection system more generally

When approaching the issue of child sexual abuse in out of home care, we faced a dilemma: how to shine a light on an important issue for the safety of Tasmanian children in out of home care at the same time as acknowledging the challenging environment of child protection and the difficulties dedicated child protection workers face in any jurisdiction.

Soon after our hearings on out of home care in June 2022, a series of media articles highlighted problems in statutory child protection in every Australian jurisdiction.3 Tasmania is not alone in facing the challenge of safeguarding children in care. However, the magnitude of the challenge should not deter those involved from continuing to try to improve the systems charged with protecting Tasmania’s most vulnerable children, who have the right to be shielded from harm and given every opportunity to grow and thrive.

As former Child Safety Service staff told us, not only are many of the children who have been taken into care traumatised by their experiences of abuse and neglect, so too can the staff tasked with protecting them. We acknowledge that in scrutinising a traumatised system, people in that system may perceive our Inquiry as threatening.

We were reluctant to add to the stress that overburdened staff already feel. We consider most staff in the system are working to the best of their ability under difficult conditions and are often underappreciated. We acknowledge the skill and dedication required to work in child protection. To do their jobs well, Child Safety Service staff need to be enormously resourceful, particularly those on the ‘frontline’. As a former Department employee noted in her statement:

Many children and young people heal and thrive, due in no small part to their own extraordinary resilience and determination, and the commitment of those who care for them. This includes staff working in [the Child Safety Service], our service providers, our foster and kinship carers, and those supporting the [out of home care] system.4

We consider there should be greater accountability for Tasmania’s out of home care system. Increased accountability for Government would motivate it to prioritise and assign the necessary resources to ensure the system works for the benefit of children in care. Increased accountability for executive staff would help to establish priorities, maintain the necessary structures and processes, and provide the leadership required to enable the out of home care system to operate safely for children in care.

We are also conscious that, because of our Inquiry, there will be families of children in care who become concerned about whether their children have been sexually abused. Family members may reasonably ask questions of the Child Safety Officer who is responsible for their child in care. We hope they will receive honest and transparent answers to their questions and be reassured that any known risks have been addressed.

While the scrutiny brought by our Inquiry may be unwelcome for some, there are many others who have bravely come forward because they believe, as we do, that the most vulnerable children in Tasmania—those who experience hurt, damage and shame, and are often forgotten—deserve the best possible protection from abuse, or further victimisation, when in out of home care. We have strived to be direct and honest in our assessment of the current system and of what needs to occur in future

This volume has three chapters. In Chapter 7, we cover the background and context for our Inquiry, describing Tasmania’s out of home care system, discussing the risk factors and sources of risk for the sexual abuse of children in out of home care. We summarise the numerous reviews of the out of home care and child protection systems in Tasmania.

In Chapter 8, we outline our approach to inquiring into the out of home care system in Tasmania, including the scope of our Inquiry, the evidence we drew on and the picture we formed of the scale and nature of child sexual abuse in the system.

In Chapter 9, we analyse the systemic problems of out of home care in Tasmania that expose children to greater risk of sexual abuse. We make recommendations to change the system to measurably improve the safety and wellbeing of children in care.

1. Introduction

In this chapter, we lay the foundation for our later analysis by understanding the Tasmanian out of home care system as it currently functions.

In Section 2, we describe the current arrangements for out of home care provision in Tasmania. We outline the legislative basis for the State removing a child into out of home care and the responsibilities of the statutory guardian of children in care—the Secretary of the Department. We detail the number of children in the various types of out of home care provided in Tasmania. Last, we describe the Department’s organisational structure in relation to out of home care.

In Section 3, we briefly outline the risks and protective factors for sexual abuse of children in care identified by the National Royal Commission. Sources of risk include adults in the out of home care system, other children with whom children have contact while in care, and adults from outside the system who sexually exploit children in care. We identify the increased risk that some children face by virtue of their Aboriginality or disability.

Section 4 summarises the findings of the National Royal Commission, as well as those of the many reviews and reports into the out of home care and child protection systems in Tasmania that have been published since the early 2000s. We briefly consider the large number of recommendations that were made by these reviews but were too often not actioned.

1. Tasmania’s out of home care system

In this section, we have attempted to describe the out of home care system in Tasmania. This was not an easy task. Our understanding of the system was derived from multiple sources and we have highlighted any contradictory information.

1. Defining ‘out of home care’

The Department defines out of home care as:

… the system that provides formal care to children and young people who are assessed as unable to live safely at home. Where the Child Safety Service assesses that a child or young person is at risk in their home, they will seek a court application for the short or longer term care for those children and young people and an out of home care arrangement will be made for their day to day care. The Secretary of the Department of Communities Tasmania then becomes responsible for the care and protection of those children and young people.5

The Department’s definition is broadly consistent with the nationally agreed definition of out of home care, namely: ‘overnight care for children aged under 18 who are unable to live with their families due to child safety concerns’, including ‘placements approved by the relevant department for which there is ongoing case management and financial payment’.6 Since 2018, for data collection purposes, the nationally agreed definition of out of home care has not formally included children on third-party guardianship orders. However, we consider that the Department still owes these children protection from abuse in care because the Department is the entity that statutorily intervened to remove the child from their family of origin and assigned guardianship or custody to a third party.7 We explore this issue in more detail in Chapter 9.

In recent decades, Tasmania has followed other Australian jurisdictions in changing the way out of home care is provided. The out of home care model has moved from primarily housing children in large institutions to placing children in home-based settings with kinship or foster carers. Some children are still cared for in residential care settings, but these usually aim to be home-like and are small in scale.8 Decreasing numbers of carers and increasing numbers of children in care have created, by necessity, new care types such as ‘emergency care’, which has paid rotational carers looking after children in temporary accommodation such as hotel rooms.9 Different categories of out of home care are discussed in more detail in Section 2.5.

In Tasmania, the out of home care system primarily comprises the Department and non-government services that provide support to children on the Department’s behalf. A range of government and non-government agencies also support ‘the system’. These agencies are responsible for meeting the broad needs of children (including health, education and disability) and should play a part in protecting children.10

In this chapter, a reference to a child who is ‘in out of home care’, ‘in care’ or ‘in the care of the Department’ means a child who has been placed under the guardianship or custody of the Secretary—this includes children under a third-party guardianship order (their guardian is not the Secretary) following statutory removal by the Department, as the State retains obligations to protect such children.

1. A child’s pathway through the system

1. Entering care

The Department typically becomes aware of a child who is at risk of abuse or neglect when someone who is concerned about the child contacts the Department’s Strong Families, Safe Kids Advice and Referral Line ('Advice and Referral Line'). If staff on the Advice and Referral Line believe there is sufficient concern to warrant an assessment, they refer the matter to the Child Safety Service, whereupon a Child Safety Officer assesses the situation.11

If the assessment determines that the child needs care and protection, the Secretary can apply to the Magistrates Court (Children’s Division) for a care and protection order for the child.12 If the Court is satisfied that the child is at risk and that a care and protection order is necessary, it may make an order placing the child under the guardianship of the Secretary (among other possible orders).13 Placing a child under the guardianship of the Secretary is a last resort, when a child cannot be properly protected from risk by any other means, and no other order would be in the child’s best interests.14 A child may be placed in care for a short time (for example, six months) or for a long time—sometimes until the child turns 18 years old.

Once a child has been placed under the Secretary’s guardianship, the Secretary is responsible for deciding where the child should live, making arrangements for the child’s education and medical treatment, and making any other arrangements for the child’s care (these responsibilities are discussed in Chapter 9).15 Increasingly, child protection departments across Australia are recognising that their obligations to support and care for children in care do not end when the child turns 18, with several states announcing extensions of support to the age of 21.16

When a Child Safety Officer collects the child to take them into care, they need to find somewhere for the child to stay until a longer-term arrangement can be made. Sometimes the Child Safety Officer can place the child with a family member (kinship care), but often the Child Safety Officer needs to find a temporary non-familial ‘placement’. Respite carers or foster carers might look after the child until a decision is made about where the child should ultimately live.

The Child Safety Officer will try to find a foster family that is suitable for the child in the longer term. Often children will live with several foster carers throughout their time in care. For some children, their time in care is short-lived, but others ‘grow up in care’, living with carers or workers for more than a decade. Where possible, the number of placements is kept to a minimum, but many children live in multiple homes or settings, which can be unsettling and reinforce their sense of instability and rejection.

Some children cannot be placed with a foster family and are therefore placed in ‘residential care’, which is usually a house where the child lives on their own or with other children, under the supervision of youth workers or other paid carers. Although considered an option of ‘last resort’, many children are placed in residential care due to a lack of available foster or kinship carers, particularly a lack of carers who can meet the needs of children who are older, children with behavioural and mental health issues or those with disability. For some, residential care is the best placement option, but for many, residential care can be marked by an ongoing sense of a lack of safety and can lead to poorer outcomes.

The Department funds non-government organisations to provide some foster care and all residential care. The child’s allocated Child Safety Officer supports the child on behalf of the Secretary, including by enrolling the child in school and ensuring they stay connected with their family of origin. Foster, kinship or paid residential carers provide the child with day-to-day physical, emotional and cultural support. Where a non-government service provider is contracted, it supports the carers to carry out their role.

At the time of writing, the Department had a team of Child Safety Officers who support the Department’s own foster and kinship carers. These officers are separate to the Child Safety Officers who support children.

1. While in care

Children do best when they are surrounded by a network of supportive adults who understand and respond to their needs. While in care, it is the Department’s policy that a child has a care team around them, coordinated by a Child Safety Officer.17 This team should include important adults in the child’s life—such as their carer, teacher, counsellor and paediatrician or doctor—and a representative from their cultural community (this is particularly important for Aboriginal children).18

The Department’s policy is that the care team should meet regularly to develop and monitor the child’s care plan. The plan should outline the child’s needs and who is responsible for meeting those needs, and be updated to reflect the child’s changing needs. Depending on the child’s age, they may have a say in the plan through attending care team meetings.19

Members of the care team are jointly responsible for keeping the child safe from sexual abuse. They develop trusting relationships with the child, so if a child wants to disclose a concern about sexual abuse, they may feel comfortable to talk to a trusted adult in their care team. The Child Advocate can also help a child raise a concern or get help if they are not feeling heard. When a child (or anyone else) raises a safety concern or discloses abuse, the Department uses its ‘care concern process’ to investigate the matter (discussed in Chapter 9).

1. The Secretary’s responsibilities as guardian

Under the Children, Young Persons and Their Families Act, the Secretary is conferred ‘the same rights, powers, duties, obligations and liabilities as a natural parent of the child’ when assigned guardianship.20 These duties include:

• deciding where the child will live, being mindful of securing a stable home21
• arranging education and medical care, and providing anything else that is necessary (including financial assistance)22
• providing for the physical, intellectual, psychological and emotional development of the child23
• reviewing the child’s care and protection order to ensure it is still in the child’s best interests.24

In carrying out the duties and responsibilities of a guardian, the Secretary must consider the best interests of the child to be paramount.25 This is one of the objects of the Children, Young Persons and Their Families Act, and the guiding principle that underpins all decisions the Department makes in relation to children.26 The Secretary relies on a detailed instrument of delegation to exercise these duties and responsibilities through departmental staff.27

Section 10E of the Act sets out a range of matters that must be considered in determining the best interests of a child. These matters are directly relevant to reducing the risk of child sexual abuse for children in out of home care.

Section 10E of the Children, Young Persons and Their Families Act

1. In performing functions or exercising powers under this Act, the best interests of the child must be the paramount consideration.
2. Without limiting the matters that may be taken into account in determining the best interests of a child, the following matters are to be taken into account for that purpose:
   1. the need to protect the child from physical, psychological and other harm and from exploitation;
   2. the views of the child, having regard to the maturity and understanding of the child;
   3. the capacity and willingness of the child’s parents or other family members to care for the child;
   4. the nature of the child’s relationships with his or her parents, other family members and other persons who are significant in the child’s life, including siblings;
   5. the child’s need for stable and nurturing relationships with his or her parents, other family members, other persons who are significant in the child’s life and the community;
   6. the child’s need for stability in living arrangements;
   7. the child’s physical, emotional, intellectual, spiritual, developmental and educational needs;
   8. the attitude to the child, and to the responsibilities of parenthood, demonstrated by each of the child's guardians;
   9. the need to provide opportunities for the child to achieve his or her full potential;
   10. the child’s age, maturity, sex, sexuality and cultural, ethnic and religious backgrounds;
   11. any other special characteristics of the child;
   12. the likely effect on the child of any changes in the child’s circumstances;
   13. the least intrusive intervention possible in all the circumstances;
   14. the opportunities available for assisting the child to recover from any trauma experienced—
       1. in relation to being separated from his or her parents, family and community; or
       2. as a result of abuse or neglect;
   15. any persuasive reports of the child being harmed or at risk of harm and the cumulative effects of such harm or risk.

1. The number of children in care

The number of children in out of home care in Tasmania is reported monthly on the Department’s website.28 In April 2022, the website stated that 1,256 children were in out of home care in Tasmania; however, Michael Pervan, then Secretary, Department of Communities, reported that 1,034 children were in out of home care in the same period.29 Secretary Pervan explained that the figures reported on the website include children on third-party guardianship orders.30 For the sake of clarity, we will state whether data includes children on third-party guardianship orders where it is relevant to do so.

Since 2007, the number of children in out of home care in Tasmania in any given year has fluctuated, although the trend has been an increase (refer to Figure 7.1).

Figure 7.1: Number of children in out of home care in Tasmania, excluding third-party guardianship orders, from 30 June 2000 to 30 June 202131

Source: Australian Institute of Health and Welfare, Child Protection Australia reports 2000–01 to 2020–21.

Given Tasmania’s small population, it is also worth considering the relative number of children in care in Tasmania compared with other Australian jurisdictions. At 9.6 per 1,000 children in out of home care, Tasmania sits above the national average of 8.1 per 1,000 children (Figure 7.2).32

Figure 7.2: Rate of children per 1,000 in out of home care by state and territory33

Source: Australian Institute of Health and Welfare, Child Protection Australia 2020–21.

1. Types of out of home care

In her first Monitoring Report, covering 2018–19, Leanne McLean, Commissioner for Children and Young People, outlined the characteristics of the different forms of out of home care provided in Tasmania as follows:

Foster care: A form of [out of home care] where the caregiver is authorised and provided a contribution for the cost of care by the state/territory for the care of the child. (This category excludes relatives/kin who are provided a contribution for the cost of care).

For Aboriginal and Torres Strait Islander children, a kinship carer may be another Indigenous person who is a member of their community or a compatible community or from the same language group.

…

Residential care: Where the placement is in a residential building whose purpose is to provide placements for children where there are paid staff. It appears through monitoring activities that the term ‘residential care’ is used by [out of home care] providers to describe [out of home care] arrangements provided to children and young people by paid staff on a rostered 24/7 basis. Within this broad definition, arrangements of this sort ranged from a single child or young person living in a house with paid staff to two or more children and young people (who may or may not be related) living in a house with paid staff.

Respite care: A form of [out of home care] used to provide short-term accommodation for children and young people, where the intention is for the child to return to their prior home. In family-based [out of home care], this may be planned and regular to give the child’s usual carers, parents or guardians a break.

…

Third-party guardianship: Transfer of guardianship to a third party is where a person other than the Secretary may be granted guardianship for a child or young person under a care and protection order. Under such an order, the guardian has the same rights, power, duties, obligations and liabilities as a natural parent of the child or young person would have.34

The Department describes sibling group care as ‘a placement option for groups of three or more connected children who cannot be placed together in foster or kinship care’.35

More recently, the Department has funded children in residential care under ‘special care packages’, which were intended to enable ‘a specific child’s extraordinary level of need for care to be matched to care options including therapeutic, medical, disability or similar support’.36 We discuss concerns about the Department’s Special Care Package funding in Chapter 9.

Commissioner McLean reported that some children have ‘independent living’ arrangements.37 Such arrangements presumably involve older children in care living independently, either in private or supported rental accommodation.

Table 7.1 sets out the most recent figures for the number of children in out of home care in Tasmania by the form of care (or type of placement). The table does not include children on third-party guardianship orders. National figures are included for comparison. The data indicates that:

• Like other jurisdictions, most children in out of home care in Tasmania live in a home-based environment.
• Within home-based care types, Tasmania has a higher proportion of children in foster care than in kinship care arrangements.
• Tasmania has a slightly lower proportion of children in residential care environments.

Table 7.1: Children in out of home care in Tasmania by type of placement, 2020–2138

Type of placement	Number of Tasmanian children	Placement type, Tasmania (%)	Placement type, national (%)
Foster care	556	51.6	36.1
Relative/kinship care	449	41.7	53.7
Other home-based care	0	0.0	1.3
Total home-based care	1,005	93.3	91.1
Family group homes	0	0.0	0.3
Residential care	64	5.9	7.3
Independent living	Not published due to small numbers	Not published due to small numbers	0.5
Other/unknown	Not published due to small numbers	Not published due to small numbers	0.8
Total	1,077	100.0	100.0

Source: Australian Institute of Health and Welfare, Child protection Australia 2020–21.

1. Government and non-government providers

Out of home care in Tasmania is a ‘hybrid system’, where the Department directly provides some out of home care services and others are provided by Department funded non-government providers.39

The Department’s out of home care ‘service directory’ maps the funded services available for children in out of home care under the categories of ‘family-based care’ (foster and kinship care) and ‘salaried care’ (residential care). Available funded support services are also independently listed in the directory.40 This directory is reproduced at Figure 7.3.

Figure 7.3: Out of home care service directory provided by the Secretary41

We heard that the Department directly provides kinship care, foster care and respite care. It also supports children who are in independent living arrangements or on third-party guardianships.42 The Department is the only facilitator of kinship care, but there are plans for a non-government organisation to share support for kinship care in the future.43

Of 968 children in family-based out of home care on 22 April 2022, the Department directly facilitated the care of 700 children (72 per cent), while the remaining 268 children (28 per cent) were living in foster care arrangements overseen and supported by non-government providers.44 In 2020–21, 449 of the 1,005 children in departmental family-based care were living in kinship care.45

The non-government organisations the Department funded to provide out of home care services, or support for children in out of home care or their carers, in 2021–22 are listed in Table 7.2 (up to 22 April 2022). Several non-government providers—including Mosaic Support Services, Oak Tasmania and St Giles Society—are specialist disability support agencies.

Table 7.2: Non-government organisations the Department funded to provide out of home care services by type of service and number of children in the service, 1 July 2021 – 22 April 202246

Organisation	Service provided	Number of children who received the service on 22 April 2022
Anglicare	Special care packages	1
Australian Childhood Foundation	Special care packages and Australian Childhood Foundation-only packages	Not reported
Australian Childhood Foundation	Therapeutic assessment and review	Not reported
Australian Childhood Foundation	Therapeutic services for children in out of home care	Not reported
Australian Childhood Foundation	Therapeutic operating model for the Many Colours One Direction program	Not reported
Baptcare	Family-based foster care	15
Caring Hearts	Special care packages	1
Catholic Care	Capability – salaried care	0
Catholic Care	A team for special care packages and Bringing Baby Home program	0
Catholic Care	Special care packages	5
Choice Supports Tasmania	Special care packages	1
CREATE Foundation Ltd	Advocacy (Connect, Empower and Change program)	Not reported
Devonfield	Special care packages	0
Eskleigh	Special care packages	2
Foster and Kinship Carers Association of Tasmania	Advocacy	Not reported
Glenhaven Family Care Inc.	Emergency and respite care	3,000 (bed nights block-funded)
Glenhaven Family Care Inc.	A team for special care packages and Bringing Baby Home program	0
Glenhaven Family Care Inc.	Family-based foster care	21
Glenhaven Family Care Inc.	Special care packages	19
iCare	Special care packages	1
Inglis Support Services	Special care packages	1
Kennerley Children’s Home Inc.	Emergency and respite care	2,158 (bed nights block-funded)
Kennerley Children’s Home Inc.	Moving On Program (transition from care)	Not reported
Kennerley Children’s Home Inc.	Family-based foster care	105
Key Assets	Sibling group care	59 (bed nights block-funded)
Life Without Barriers	Family-based foster care	66
Life Without Barriers	Special care packages	7
Langford	Special care packages	3
Many Colours One Direction (Northern Territory)	Special care packages	0
Mosaic Support Services	Special care packages	5
MSJ Aust	Special care packages	Not reported
Nexus	Special care packages	0
Oak Tasmania	Special care packages	0
St Giles Society	Special care packages	1

Source: Statement of Michael Pervan, 7 June 2022.

The Foster and Kinship Carers Association of Tasmania advised us that Baptcare also provides statewide support for kinship carers.47

1. Number of foster and kinship carers

The Foster and Kinship Carers Association of Tasmania believes there are about 1,200 foster and kinship carers in Tasmania. Of these, the Department directly engaged about half, and non-government out of home care providers engaged the other half.48

According to the Australian Institute of Health and Welfare, on 30 June 2021 there were 566 Tasmanian households that were officially caring for at least one child in out of home care as foster carers or kinship carers.49 Table 7.3 lists the number of Tasmanian households, type of placement and number of children in each home. It shows that foster care households are more likely to have larger numbers of children in care living with them than kinship care households.

Table 7.3: Tasmanian carer households by number of children in the placement and type of placement, 2020–2150

Number of children in placement	Number of foster care households	Number of kinship care households
1	112 (41.6%)	196 (66.0%)
2	80 (29.7%)	68 (22.9%)
3+	77 (28.7%)	33 (11.1%)51
Total	269 (100%)	297 (100%)

Source: Derived from Australian Institute of Health and Welfare, Child Protection Australia 2020–21.

In addition to these figures, the Foster and Kinship Carers Association informed us of ‘thousands’ of informal kinship carers in Tasmania who are not included in official statistics and who do not have access to the same supports as formal carers.52 While we acknowledge the incredible commitment of these informal kinship carers, their situations fall outside the scope of our Inquiry because the children they care for are not in ‘institutional’ care.

1. Department structure

In October 2022, the Department of Communities’ child protection and out of home care functions transferred to the new Department for Education, Children and Young People.53 In the new Department, the child protection and out of home care systems sit under an Executive Director who reports to a Deputy Secretary for Keeping Children Safe (refer to Appendix G for the organisational structure of the new Department). The Child Advocate, whose role is described in detail in Chapter 9, reports directly to the Secretary, as was the case in the Department of Communities. The current Secretary of the Department for Education, Children and Young People is Timothy Bullard.

Given that the Department of Communities was responsible for statutory child protection and out of home care for most of our Inquiry, it is also important to understand the structure of that Department, particularly the mechanisms that were in place to protect children from sexual abuse in out of home care and to respond when they had been harmed.54

Michael Pervan was the Secretary of the Department of Communities (and its predecessor, the Department of Health and Human Services), from May 2014 to October 2022, with a gap between July 2018 and September 2019, when Ginna Webster filled the role. Before this, between 2000 and May 2014, seven people held the position at different times.55

In the Department of Communities, the Children, Youth and Families division was one of four large service divisions that each sat under a Deputy Secretary. Within this division, an Executive Director headed Children and Family Services. The Child Advocate sat outside Children, Youth and Families and reported directly to the Secretary.

Secretary Pervan described Children and Family Services as follows:

Children and Family Services … includes the Strong Families Safe Kids Advice and Referral Line, the Child Safety Service, Out of Home Care; Adoptions, Permanency and After Care Support, Intensive Family Engagement Services, and the Child Safety After-Hours Emergency Service, and is currently holding Community Youth Justice.56

We asked Secretary Pervan to describe the internal organisational structure of the Strong Families, Safe Kids Advice and Referral Line, the Child Safety Service and Out of Home Care services (which exist in the current and older organisational structures), and the ways in which these service components relate to one another on a day-to-day basis.57 He indicated the following:

• The Advice and Referral Line receives concerns about the wellbeing of a child. A brief assessment decides if the concern requires advice and referral to support services, or referral to the Child Safety Service for support or investigation.58
• Child Safety Service staff are in regional offices and receive notifications of child abuse and neglect. Child Safety Officers provide case management for children who are being assessed for risk of harm or neglect, or who are already in out of home care.59
• Out of Home Care services recruit and assess prospective foster or kinship carers, provide support to carers, monitor compliance of foster carers with requirements, and facilitate placements for children with foster carers.60

Secretary Pervan provided information on the reporting lines of staff on the Advice and Referral Line and in the Child Safety Service, as well as the full-time-equivalent staff allocation for each role (refer to Figure 7.4 and Figure 7.5). He advised us that the Child Safety Service receives more than $19.6 million in funding each year and employs 204.85 permanent full-time-equivalent staff.61 Secretary Pervan also described the Out of Home Care services staffing complement and structure, which is shown at Figure 7.6. We understand these arrangements have been augmented in the new Department by additional funding for 10 new Child Safety Officer positions and 13 new administrative roles.62 In the absence of any evidence to the contrary, we have assumed this reflects the current internal organisation of the Advice and Referral Line and the Child Safety Service.

Figure 7.4: Staffing structure of the Advice and Referral Line63

Source: Compiled from statement of Michel Pervan, 7 June 2022.

Figure 7.5: Staffing structure of Child Safety Services64

Source: Compiled from statement of Michael Pervan, 7 June 2022.

Figure 7.6: Staffing structure of Out of Home Care services65

Source: Compiled from statement of Michael Pervan, 6 June 2022.

When comparing the structure of the Out of Home Care services and the Child Safety Service, some information provided about some positions is unclear:

• the Practice Leader (Out of Home Care) positions appear in both structures but report to different managers
• the Child Safety Officer (Foster Carer Program) positions are in the Child Safety Service but would seem to sit more naturally in Out of Home Care services.

We heard that the Department’s Out of Home Care team supports departmental carers, while the Child Safety Service provides case management for a child for the length of their contact with the Department, from their referral by the Strong Families, Safe Kids Advice and Referral Line to their transition out of care.66

Claire Lovell, Executive Director, Children and Family Services, explained that the Out of Home Care teams work from three locations across the State (South, North and North West) and sit alongside the Child Safety Service teams, which provide assessment and case management for children in contact with the service or in out of home care.67

Ms Lovell told us that in June 2022 there were between 26 and 30 vacant positions across the Advice and Referral Line, Child Safety Service and Out of Home Care services.68

We heard that frontline practitioners may receive clinical supervision from senior practitioners who sit outside their direct line management; for example, staff in Out of Home Care services access clinical supervision from a Practice Manager (location unspecified) who has no line management responsibility for them.69 Secretary Pervan also told us that an unspecified number of Clinical Practice Consultants and Educators were assigned to case management and out of home care teams in the Child Safety Service statewide to support clinical practice.70 However, these roles were not included in the organisational charts or descriptions we received, so we have no other information about them.

Ms Lovell also told us that, in addition to the out of home care staffing contingent outlined above, the Manager of Strategic Commissioning, who sits outside the Children and Family Services portfolio, is responsible for engaging and contracting non-government organisations to provide out of home care services (among other commissioning activities for the Children, Youth and Families division).71 She advised that this single role has limited capacity to oversee non-government organisations’ compliance with contractual obligations.72 Instead, oversight of contractual obligations is ‘spread to different positions in different ways’ between Child Safety Officers, reviews by the Australian Childhood Foundation and reports received from non-government agencies.73 We discuss the need to improve commissioning in Chapter 9.

1. Child sexual abuse in care: risks and protective factors

The National Royal Commission heard horrific accounts of abuse in ‘old-fashioned’ care institutions. It also found that many children were still experiencing sexual abuse in contemporary out of home care:

Despite reforms in every jurisdiction, there are weaknesses and systemic failures that continue to place children in care at risk of sexual abuse. Abuse by carers, family members, visitors and workers still occurs, and sexual exploitation, especially of children in residential care, is an emerging concern. Frequent placement changes, poor information sharing, gaps in training and supports, especially to kinship carers, still exist. Given the increasing number of children in care and the inherent vulnerability of children in care, such weaknesses need to be addressed.74

Despite the National Royal Commission having reported over five years ago, we heard that similar problems still exist in Tasmania. These problems are discussed throughout this chapter.

1. Factors that increase risk

As mentioned in Chapter 3, the National Royal Commission identified several factors that increase the risk of child sexual abuse.75 Characteristics specific to the out of home care context that increase risk of child sexual abuse include:

• situational factors, such as aspects of the physical environment; the dislocation from culture that can occur when Aboriginal children are placed with non-Aboriginal families; a lack of culturally sensitive supports for children from culturally diverse backgrounds; and the absence of trusted adults created through disconnection from family and placement instability, including frequent placement moves76
• vulnerability factors, such as children lacking an understanding that particular behaviour is sexual abuse, prior maltreatment, being younger, having disability, or having a history of trauma or mental illness, which are disproportionately more likely in out of home care populations than the broader community77
• propensity factors, such as the risk of abusers targeting children in residential care settings for the purposes of child sexual exploitation78
• institutional factors, some of which are particularly associated with residential care, including:
  • placement of vulnerable children with other children or within families where they are at greater risk of harm (due to poor assessment, placement matching and monitoring)79
  • inadequate professional development and supervision of staff, lack of role clarity for staff and unclear expectations of relationships between staff and young people80
  • the absence of policies and procedures that protect children in care from sexual abuse, and an organisational culture that does not actively promote child welfare81
  • inconsistent data collection and reporting among service providers, making it difficult to monitor incidents and responses82
  • large caseloads that overwhelm child protection staff, reducing their ability to respond and their frequency of visits to children in care83
  • low remuneration, work stress and public criticism of child protection staff, making it difficult to attract and retain highly skilled staff.84

We identified that most of the institutional risk factors are present in Tasmania’s statutory child protection system. In Chapter 9, we explore the policies and practices that the Department should adopt to reduce these and other risk factors as they relate to out of home care.

The National Royal Commission, Australian and international research has shown that children and young people in residential care are more likely to experience child sexual abuse, peer sexual victimisation and sexual exploitation than their peers in kinship and foster care (who are still at greater risk than those who do not live in care). This is often because children in residential care are more likely to have behavioural and mental health issues, have disabilities and be older than children in other placement types. They tend to lack a stable and secure relationship with a trusted adult and are also more likely to be placed with peers who engage in harmful sexual behaviours.85

1. Sources of risk

The main sources of risk for children in out of home care are the adults working in the statutory child protection system or other adults in their lives. Another source of risk is other children in the out of home care system.

1. Adults working in the child protection system

We recognise that most adults in the out of home care system are hard-working and committed people who are trying to provide children with the supports they need. Despite these positive contributions, the nature of out of home care—whereby foster carers and their family members, Child Safety Officers and staff from non-government organisations contracted by the Department have opportunities to be alone with children outside of public view—means that children are exposed to a greater risk of child sexual abuse.

Research commissioned by the National Royal Commission found the following:

• adults who sexually abuse children in out of home care settings are more likely to be male, charismatic, controlling and in positions of power86
• such abuse is often accompanied by grooming so children will trust the abuser and believe they have consented to the abuse87
• such abusers can engage in ‘institutional grooming’ where they manipulate systems and communities into trusting them and setting them outside the usual safety nets that exist to prevent child sexual abuse, and so can abuse multiple children over long periods.88

The National Royal Commission noted that it can be difficult to distinguish grooming from legitimate caring activities, particularly where the abuser is a carer. A key aspect of grooming is creating a trusting relationship with the child and making them feel special and cared for—the same behaviours we want from carers. Grooming is often associated with boundary breaches, such as taking a child on an unauthorised shopping trip or supplying them with alcohol, drugs or cigarettes.89

We heard of several instances of departmental staff having engaged in grooming behaviours and boundary violations. We identified many more allegations of sexual abuse of children by foster carers and adults associated with foster families. These issues are discussed in Chapter 8.

We address measures that can, reduce the risk to children in care from adults in the out of home care system in Chapter 9.

1. Adults outside the child protection system: child sexual exploitation

The National Royal Commission defined child sexual exploitation as arising when ‘children are coerced or manipulated into engaging in sexual activity in return for something (such as alcohol, money or gifts)’.90 It can take different forms, including the child perceiving it as a ‘loving relationship’ and the adult manipulating the child into sex work. It can also include the production, consumption, dissemination and exchange of child sexual exploitation material.91 The abuser may meet the child in the community but often initially grooms a child online. In the context of out of home care, the relationship with the abuser is sometimes initiated by other children in care.92

In addition to unknown adults from the community, children in care may be at risk of child sexual abuse from adults and other family members from within their families of origin while on unsupervised contact visits. We heard of only a few instances of this form of harm.

We focus on the risk of child sexual exploitation and measures that are necessary to reduce the risk and respond more appropriately in Chapter 9.

1. Other children in the out of home care system: harmful sexual behaviours

The National Royal Commission noted that the out of home care sector has been aware of risks to children in out of home care from harmful sexual behaviours for some time; however, policies, procedures and professional development that address these risks was lacking in all Australian jurisdictions.93 The National Royal Commission also noted that therapeutic treatment programs for young people who engage in harmful sexual behaviours were under-resourced and limited in their availability.94

We also identified that a high proportion of concerns about the sexual abuse of children in care in Tasmania related to the harmful sexual behaviours of other children (refer to Chapter 8). As we discuss in Chapter 9, the Department does not have a policy for preventing, identifying or responding to harmful sexual behaviours in out of home care and has only recently funded limited specialist support for children engaging in such behaviour. Chapter 21 discusses the broader need for a coordinated approach to harmful sexual behaviours in children across Tasmanian institutional settings.

1. Over-representation of particular groups of children

In addition to specific vulnerabilities referred to above, Aboriginal children and children with disability are at increased risk of experiencing sexual abuse in out of home care due to their over-representation in the system.

1. Aboriginal children

On 30 June 2021, there were 403 Aboriginal children in Tasmanian out of home care, which is 37.4 per cent of the number of children in out of home care.95 The proportion of Aboriginal children in out of home care in Tasmania was 34.4 per 1,000 children compared with 6.5 per 1,000 non-Aboriginal children.96 This means that Aboriginal children in Tasmania are a little over five times more likely to be in out of home care than non-Aboriginal children. However, because there are high numbers of children in care whose Aboriginal status is recorded as ‘unknown’, it is likely that the number is higher than reported.97

Australia-wide, the proportion of Aboriginal children in out of home care has increased over the past five years from 57.8 per 1,000 children in 2017 to 65.7 per 1,000 children in 2021.98 Without urgent action to reverse this trend, the number of Aboriginal children in out of home care in Australia is predicted to increase by 54 per cent (to just over one in 10 children) by 2030.99

Aboriginal children are more likely to experience abuse and maltreatment in out of home care because they are over-represented and therefore ‘have more contact with high risk institutional settings’ such as ‘residential and contemporary out of home care’.100 The ongoing impacts of colonisation, the treatment of Aboriginal children in the past and subsequent intergenerational trauma continues to place them at risk.101 There is also a range of culturally specific barriers to Aboriginal children disclosing abuse.102 In Chapter 9, we examine the steps the Department is taking to address the over-representation of Aboriginal children in out of home care, and we make recommendations for more significant reforms.

1. Children with disability

The Australian Bureau of Statistics reports that 10.2 per cent of children aged 0–14 years in Tasmania have disability, which is higher than the national average of 7.7 per cent.103 When compared with the general population, Tasmanian statistics indicate that children and young people with known disability are over-represented in out of home care: 21.0 per cent have known disability, 47.2 per cent are recorded as having no disability and the disability status of the remaining 31.8 per cent of children in care is unknown.104

Research commissioned by the National Royal Commission noted that, in general, children with disability are about three times more likely to experience sexual abuse than children who do not have disability.105 There is little Australian data to understand the reasons for this increased risk, although it is likely that multiple interacting factors are at play.106

The National Royal Commission observed that children with disability in out of home care face unique challenges because services and supports are not tailored to their individual needs.107 Research commissioned by the National Royal Commission found that children with disability are more vulnerable to child sexual abuse in out of home care where:

• their disability means they need help with intimate care activities108
• they have an intellectual disability, behavioural disorder or communication disorder109
• the child and carers have little control over daily activities110
• the child is expected to be compliant111
• the child has difficulty communicating to others that child sexual abuse is occurring.112

Our examination of 22 departmental files, discussed in Chapter 8, confirmed these observations. As we explore in Chapter 9, there are several steps that the Department must take to reduce the risk of sexual abuse for children with disability in out of home care.

1. Protective factors

According to the National Royal Commission, maintaining positive connections with family, community and culture may be protective factors against sexual abuse for children in out of home care.113

The National Royal Commission heard that placing a child in kinship care increases the likelihood that he or she ‘will grow up and know that they’re loved, they’re claimed, they belong’.114 The National Royal Commission also heard that:

Children who are part of a broader community with an interest in their wellbeing are more likely to be noticed when they are in danger and have networks of support to draw upon when they feel unsafe.115

For these reasons, kinship care may offset some of the ‘psychic trauma’ for a child caused by being removed from parents, provide the child with a familiar environment with known carers and maintain ‘the perceived warmth and safety of a family during the placement process’.116 Kinship care can also provide ‘a strong parent/child relationship, family cohesion and positive social connection and support’, which are all important protective factors for children in care.117

For Aboriginal children, connection to culture can increase protective factors by ‘helping them to develop their identities, fostering high self-esteem, emotional strength and resilience’, while positive relationships with their family and communities of origin can also increase protective factors against the risk of sexual abuse.118 This is discussed in Chapter 9.

Associate Professor Tim Moore, Deputy Director, Institute of Child Protection Studies, Australian Catholic University, told us that healthy relationships with ‘trustworthy adults’ were ‘more protective than risky’:

Inquiries and research has demonstrated that children and young people who are socially isolated are more at risk of experiencing abuse than their peers who are not, while those who are surrounded by trustworthy adults who will protect them, watch out for them and intervene and be available when they have safety concerns are safer than those who are not.119

The National Royal Commission also found that children in care who had regular visits from their Child Safety Officer were less likely to be sexually abused than children who were not visited regularly.120 We explore the barriers to regular visitation in Chapter 9.

1. Previous reviews and reforms

In this section, we consider the Tasmanian Government’s progress on implementing the numerous recommendations that have been made to improve the out of home care system in Tasmania since 2000, including the National Royal Commission’s recommendations for contemporary out of home care.

1. National Royal Commission

The National Royal Commission made 22 recommendations aimed at improving the safety of children in contemporary out of home care. These recommendations encompassed:

• strengthening data collection and reporting (Recommendations 12.1–12.3)
• accrediting out of home care service providers (Recommendations 12.4 and 12.5)
• improving processes for authorising carers (Recommendations 12.6–12.8)
• developing a child sexual abuse prevention strategy (Recommendation 12.9)
• creating a culture that supports disclosure and identifying child sexual abuse (Recommendation 12.10)
• measures to strengthen the capacity of carers, residential care staff and child protection workers to understand trauma and abuse and its impact on children (Recommendation 12.11)
• measures to address the known risks of children in out of home care engaging in harmful sexual behaviours (Recommendations 12.12 and 12.13)
• measures to reduce the risk of child sexual exploitation in out of home care (Recommendations 12.14 and 12.15)
• strategies to increase placement stability to protect children in out of home care against the risk of sexual abuse (Recommendation 12.16)
• measures to support kinship carers and for children in care to maintain relationships with their birth families (Recommendation 12.17)
• developing an ‘intensive therapeutic model of care framework’ for residential care to meet the complex needs of children with histories of abuse and trauma, and regular professional development and supervision for residential care staff (Recommendations 12.18 and 12.19)
• measures to reduce the over-representation of Aboriginal children in out of home care, including full implementation of the Aboriginal and Torres Strait Islander Child Placement Principle (Recommendation 12.20)
• measures to improve out of home care systems’ responses to children with disability, including adequate assessment, and developing and implementing care plans that identify specific risk management and safety strategies for the child (Recommendation 12.21)
• supporting care leavers who experienced sexual abuse while in care (Recommendation 12.22).121

The National Royal Commission also made seven recommendations for setting up and maintaining a carers' register (Recommendations 8.17–8.23).122

The Tasmanian Government has reported on its progress towards implementing the recommendations of the National Royal Commission in annual reports and action plans since 2018, most recently in December 2022 (‘Fifth Progress Report’).123 In response to our notice to produce, the Department provided information that essentially replicated the Fifth Progress Report, with some minor additional details.124 We note that in relation to the recommendations relevant for this chapter, the main updates in the Fifth Progress Report relate to the Government’s release of the Tasmanian Out of Home Care Standards during 2022 (discussed in Chapter 9), a current review of the Children, Young Persons and Their Families Act, plans for a Carer Register to be completed by 2024 and an Out of Home Care Accreditation Framework to be completed by 2026.125

Following is an overview of the Government’s responses to the National Royal Commission recommendations. Throughout Chapter 9, we examine in detail the Government’s progress on implementing relevant National Royal Commission recommendations where they relate to specific issues identified in the Tasmanian out of home care system.

1. Tasmanian reviews and reports into out of home care

Tasmanian out of home care is a highly examined system. We identified 22 reviews or reports on out of home care or statutory child protection in Tasmania since 2003, which, in total, contained several hundred recommendations. Of the 22 reviews or reports, 13 were either planned or responses to known general challenges facing the sector and nine were prompted by public reporting of specific adverse care situations. The reports were prepared by various entities, including the Commissioner for Children and Young People, the Tasmanian Auditor-General and the Tasmanian Government.

While most of the reports did not consider the issue of child sexual abuse in out of home care in detail, all raised important issues about out of home care in Tasmania and features of the system that increase the risks of child sexual abuse in that setting. The reports repeatedly highlighted that the systems in place to protect children from abuse and neglect, including child sexual abuse, had not performed in the way intended.

The remaining nine reports were strategic documents about out of home care or child protection in Tasmania that outlined the various attempts at reform in response to the recommendations made in the various reviews.

The Department has initiated three main reforms to out of home care since 2003: the Out of Home Care Strategic Framework (2007), Out of Home Care Reform in Tasmania (2014) and the Strategic Plan for Out of Home Care in Tasmania (2017). All reforms were ambitious and aimed to improve the experience of children in out of home care. Alongside these reforms, the Department has attempted two main reforms of the child protection system, the most recent being the ‘Strong Families, Safe Kids’ redesign. These reforms are discussed in Section 4.2.

However, despite attempts to reform Tasmania’s child protection and out of home care systems, reviews continue to identify similar problems that directly affect the experience of children in care and increase their risk of child sexual abuse. These include:

• insufficient support for carers
• poor recruitment practices and insufficient support and professional development for staff
• inappropriate placements for children
• inadequate monitoring of children in care
• poor record keeping
• too few out of home care placements compared with the number of children in need
• poor monitoring of non-government out of home care providers and governance of funding agreements
• inadequate complaints processes
• over-representation of Aboriginal children in out of home care and low compliance with the Aboriginal and Torres Strait Islander Child Placement Principle
• over-representation of children with disability in out of home care
• poor support for children taking part in decision making
• variable understanding of and compliance with the National Standards for Out-of-Home Care, and poor monitoring of compliance
• no accreditation, registration or licensing system for out of home care providers
• poor information sharing between non-government providers and the Department.

Unfortunately, these themes have changed little over time and were echoed in the evidence we heard, which we explore in Chapter 9.

Some internal changes have been achieved over the past 19 years, such as appointing the Child Advocate and the incremental implementation of the Strong Families, Safe Kids redesign. However, out of home care is not a priority in that reform, and little apparent progress has been made on implementing the 2014 reform agenda Out of Home Care Reform in Tasmania. The various reports highlight that previous reform recommendations have not always been implemented in a timely manner, have been under-resourced or, when implemented, have not been subject to appropriate monitoring and oversight to ensure the intended outcomes are achieved.

Importantly, underfunding of statutory child protection was raised with us repeatedly as a fundamental contributing factor to the lack of implementation of recommendations over time. According to Sonya Enkelmann, a former Department employee:

There seems to be a long tradition of undertaking reviews into Child Protection/Child Safety and [out of home care] which then quietly drop from sight. Understanding what sustains this systemic inertia is difficult and I will leave that to others – but a history of chronic underfunding in the Department to build its capacity and infrastructure cannot be overlooked. I am not referring to services (although they are too often underfunded) so much as capacity – having the right people and sufficient number of people in the right jobs to manage and implement change over the long term. A system in crisis is not well placed to manage change.126

Secretary Pervan described how:

… budgetary pressure [from an expenditure overrun on special care packages] … resulted in an immediate loss of impetus for, and opportunity to, resource significant operational reforms in Family Based Care, which were suspended.127

He added that ‘the Government has been consistent in not providing funds to the Department … to implement change’, citing this factor as fundamental to the slow progress towards improving systems in the Department.128

In her statement, the Child Advocate also noted the pattern of repeated reviews and little change, commenting that ‘Tasmania is guilty of partial reform’ and needs ‘doers not reviewers’.129 She attributed this inertia to ‘significant leadership churn’ in the executive, underfunding of reforms, the lack of a focused change management team in the corporate structure and distraction caused by the demands of external scrutiny.130 Other former senior departmental employees expressed similar views.131

Ms Lovell acknowledged that the Child Safety Service struggles to ‘keep up with reasonable community expectation around the services that we deliver and the safety and quality of those services’, as well as the demand on the service. She stated that efforts to reform the service have been repeatedly interrupted by new concerns demanding their focus:

… we acknowledge that we’re not doing well in relation to one aspect; we commit to doing better, we have a strategy around how to do that, but it’s immediately superseded by the next area where it’s determined that we’re failing, and so on and so on.132

When providing evidence to our Inquiry, Ms Lovell’s frustration was clear:

We can’t do everything at once, so the expectation on us—we certainly agree that we need to improve in all of those areas. That’s what continuous improvement is about. But we can only do so much at once, and the more things we try and do simultaneously, it seems, the more that our efforts are diluted and we don’t do anything as perfectly as we would aspire to.133

We imagine this sense of not being able to ‘catch up’ on reforms has affected the morale and culture of the Child Safety Service and those working in the out of home care sector.

Inertia in implementing recommendations of inquiries and reviews is not unique to Tasmania. Analyses of previous inquiries for the National Royal Commission highlighted factors that enable and constrain reforms in the child protection and out of home care systems. Central to successfully implementing reforms are effective leadership, adequate resourcing and sufficient internal and external accountability.134 We explore these factors in relation to the Department in Chapter 9.

We are aware that our Commission of Inquiry is yet another review, with the potential to cause harm if our scrutiny does not translate into change. With this in mind, we aspire to recommendations that will help create a system that can sustain a journey of continuous improvement. Dr Samantha Crompvoets, an expert on organisational change processes, told us that sustainable organisational change can be achieved, but it can take a long time. She recommended regularly evaluating the impact of the change to track progress, breaking it down into manageable steps.135 We recognise that even with the best leadership and systems of accountability, the reforms we recommend will not lead to meaningful improvements for children without the commitment of the Tasmanian Government to provide the infrastructure and resources to enable the Department to drive and sustain change.

We recognise that the Department has been undergoing change for many years and may well be fatigued by the partial reforms. While we have compassion for the people within an overwhelmed and underfunded system, it is our view that little meaningful change has been sustained for children and their families or carers. Improved experiences for children in care must be the benchmark for success, and a system that is enabled to create and sustain change is urgently required to achieve this outcome. We outline our recommendations for reform in Chapter 9.