Content warning

Please be aware that the content in this report includes descriptions of child sexual abuse and may be distressing or raise issues of concern for some readers.

We encourage readers to exercise discretion in their engagement with this content and to seek support and care if required.

1. Introduction

In this chapter we outline our approach to inquiring into the out of home care system in Tasmania. This includes the scope of our Commission of Inquiry, the evidence we drew on and the picture we formed of the scale and nature of child sexual abuse in this system.

1. Interpreting our scope

When considering the issue of sexual abuse of children in out of home care, we needed to establish the scope of our Inquiry.

First, the out of home care system sits within the broader statutory child protection system. For reasons discussed below, we have focused on out of home care specifically, and only include those aspects of the wider statutory child protection system that relate to the risk of sexual abuse for children in care.

Second, we decided to consider all aspects of out of home care in Tasmania that might affect the risk of sexual abuse to children. We explain our rationale later in this section.

1. Focusing on out of home care, not the whole of child protection

As discussed in Chapter 7, out of home care in Tasmania is part of the wider child protection system and sits alongside the Child Safety Service and Strong Families Safe Kids Advice and Referral Line (‘Advice and Referral Line’) functions in the Department.

Had we interpreted our terms of reference broadly, we might have inquired into the child protection system as a whole, on the basis that preventing children from entering out of home care would protect them from experiencing child sexual abuse while in care. With the exception of our discussion of the Aboriginal and Torres Strait Islander Child Placement Principle in Chapter 9, we have not adopted this interpretation, because the core business of the child protection system is to respond to abuse and neglect in a familial, rather than institutional, setting. Moreover, the time and resources allocated to our Inquiry do not allow us to do justice to a review of the entire child protection system in addition to our inquiries into the health, education and youth detention systems. We note that the National Royal Commission did not examine the child protection system as a whole but similarly limited its inquiry to the out of home care system.

For these reasons, we have limited our Inquiry to those aspects of the Advice and Referral Line and Child Safety Service functions that relate directly to children who have been taken into the Department’s care. For example, Child Safety Service decisions about where a child will live once a guardianship order has been made are within the scope of our Inquiry, whereas the actions of Child Safety Service staff in relation to children who are not yet in the care of the Department are outside the scope. Our decision to consider these aspects of the Department as out of scope should not be interpreted as an endorsement of these functions in Tasmania. In hearings and sessions with Commissioners, we heard evidence of problems in the statutory child protection system’s responses to sexual abuse in and out of family settings. These included failings of the Advice and Referral Line and the Child Safety Service more broadly.1 What we heard, while outside the scope of our Inquiry, was concerning.

Between 2000 and 2021, the rate of children in out of home care in Tasmania rose substantially from 548 children on 30 June 2000 (4.6 per 1,000 children living in Tasmania) to 1,077 children on 30 June 2021 (9.6 per 1,000 children).2 During the same period the number of children living in Tasmania decreased.3 Even more concerning, for every 1,000 Aboriginal children living in Tasmania in June 2021, 34.4 were in out of home care. This over-representation is a direct and continuing effect of colonisation.4

These figures show that the system is not preventing children from entering out of home care. The most effective strategy to prevent child sexual abuse in out of home care is for families and communities to be supported to keep children safe in their families of origin. This requires an appropriate child safety system.

We heard evidence about the importance of early intervention and prevention in an effective child safety system.5 However, we caution against using the term ‘early intervention’ without being specific about the context and purpose of that intervention, particularly as the new Department brings together a broad range of children’s services. For example, early intervention could be used to refer to intervention with:

• children in the early years
• families in need of support
• families with multiple and complex needs who are known to statutory child protection
• adolescents at risk of entry into youth justice, school disengagement or early parenting.

During our hearings, we heard from multiple witnesses about the significant number of children and their families in need, and the complexity of those needs that stem from a range of circumstances and experiences.6

There is also growing evidence of intergenerational contact with the statutory child protection system; that is, the children likely to end up in the system are often those born to parents with complex needs who themselves have had contact (perhaps for multiple generations) with the system. This research shows that most families known to the child protection system have multiple profound impacts that accumulate over time and need intensive therapeutic responses.7 Concerns have been raised about whether the dominant governmental model of providing general family support is effectively meeting such multiple and complex needs.8 Unmanaged mental illness, substance addiction, domestic violence and housing instability are common features in families known to statutory child protection.9 A whole of government response is required to prevent these problems and treat children and adults for their impacts as well as the effects—often intergenerational—of abuse and neglect.

We note the results of the Australian Child Maltreatment Study, which showed that 62.2 per cent of the Australian population had experienced at least one form of child abuse, maltreatment or neglect.10 The study also showed that this is not merely a historical problem: 40.2 per cent of young people aged 16–24 had experienced two or more forms of child maltreatment.11 The study further showed that Australians who have experienced abuse and neglect are likely to experience profound mental health impacts.12

Given this context, we do not suggest a review of the statutory child protection system in Tasmania. Such a review would fail to address the factors that result in children and families becoming known to the Advice and Referral Line and the Child Safety Service.

Instead, we urge the Tasmanian Government to focus its efforts and resources on ensuring that it has a whole of government response to meeting the health and human service needs of children and adults who have experienced abuse or neglect. To break the intergenerational cycle of involvement in statutory child protection, the Government should provide coordinated responses that address the support and specialist intervention needs of:

• first-time parents with childhood histories of abuse and neglect
• families who have complex needs in which children have experienced abuse and neglect
• children and young people in out of home care and youth detention who are struggling to overcome the impacts of violence, abuse and neglect.

Using the language of a public health model, we see these as tertiary therapeutic needs that require an appropriate response (in addition to primary and secondary child abuse prevention and family support services) to serve the volume of families in this situation.

1. A broad understanding of out of home care

Within the out of home care system itself, we have taken a broad approach to our Inquiry to fully appreciate the risks and potential sources of protection for children in care.

While the sexual abuse of children in care remained central, many victim-survivors shared with us other experiences they had of violence, abuse and neglect in care. For some, these other experiences of abuse and neglect occurred alongside the sexual abuse; for others, their maltreatment increased their vulnerability to sexual victimisation and harm.13

In addition, the structures and processes to protect children from harm in out of home care are often the same as those needed to maintain children’s wellbeing and care generally. Effective structures and processes provide children with trusted and responsible adult supervision and care, give children a voice, meet children’s needs, and establish clear and supported avenues for raising and addressing concerns.

1. Evidence we have drawn on

Our understanding of the Tasmanian Government’s responsibility for children in care is based on the extensive research from the National Royal Commission about the risks of child sexual abuse for children in out of home care.

We received information from numerous sources about the experiences of children in out of home care. These included submissions, community consultations, written and oral evidence at our hearings, and documents produced by the Tasmanian Government. We received targeted information about out of home care from the following sources:

• a stakeholder consultation session for non-government providers of out of home care held in Hobart on 25 October 2021
• the relevant sections of Child Safety Service files for 22 children who were in care between 2000 and 2021 and were recorded as having been at risk of child sexual abuse while in care14
• evidence provided in the out of home care hearings held in Hobart from 14 to 17 June 2022
• statements from local and interstate experts on preventing and responding to sexual abuse of children in out of home care
• material that was publicly available on the websites of the Department of Communities and the Department for Education, Children and Young People
• internal material available to staff on the Department of Communities and the Department for Education, Children and Young People’s intranet
• strategic documents and reports, some of which were publicly available and some of which the Tasmanian Government provided in response to our notice to produce
• previous reviews and reform agendas for out of home care in Tasmania.

1. Evidence from children in care and victim-survivors

We considered it essential to understand the experience of out of home care from those people who spent time in care because they can best identify how the out of home care system has affected them.

We heard from children who live in out of home care about their experiences of the system as it is today. Many children, including those currently in out of home care, shared their experiences through a research project we commissioned from Associate Professor Tim Moore and Emeritus Professor Morag McArthur (refer to Chapter 1).15

In sessions with a Commissioner and through oral evidence at hearings, we heard directly from victim-survivors who recalled being sexually abused in out of home care as children. We also heard from their carers and family members.

We closely tracked the journey of some children in the 22 files we received from the Department (refer to Section 4).

The following case examples illustrate common experiences.

Case example: Azra

The alleged abuse

Azra told us that she does not know why she came to be in out of home care but that she was very young at the time.16 In the 1990s, Azra recalled being placed in a foster home where she experienced physical and emotional abuse from her foster mother.17 She said that once, when she was about five years old, her foster mother broke her arm and then slapped her for crying in pain.18 Azra described her foster father as ‘loving but passive’ and said that he did not protect her from her foster mother’s abuse.19

Azra felt unloved and unwanted, so when a person associated with the foster family started paying her attention, she said she experienced this attention as love.20 When this man began to sexually abuse her, she did not identify what he was doing as wrong and even sought out his company to escape her foster mother’s cruelty.21 When one of her foster father’s work colleagues also started sexually abusing her, Azra told us that she also did not recognise this as wrong.22 In Azra’s words, she only realised much later in life, when she had children of her own, that she had not recognised ‘wrong love’.23

Azra said she recalls very few visits from her departmental case worker and reflected that she may have been able to tell her case worker about the physical and sexual abuse if she had seen her more often.24 She thinks that the Department trusted the carers because of their standing in the community.25 Later in life, friends of her foster parents admitted to Azra that they knew about her abuse and apologised for not doing or saying something.26

After Azra’s sibling told someone about their foster mother’s physical and emotional abuse, a representative of the Department interviewed Azra at school.27 However, Azra’s foster mother was present at this interview, so Azra was too frightened to tell the truth.28 Azra told us that she remained in the same family until her behaviour became too extreme for them to manage, and they sent her away.29

The impact

Azra described the impact of the abuse she recalls: ‘I’m not sure I can even begin to recover and learn to live like a normal person. I’m completely ruined’.30 She said that all her romantic relationships have been violent, which she links to her ‘skewed love maps’, and she believes her childhood experiences have negatively affected her parenting, with her children suffering as a result.31 Azra said she has been diagnosed with complex post-traumatic stress disorder and has flashbacks of the alleged abuse.32 She has tried medication, therapy and illicit drugs in her attempts to cope.33 She attributes still being alive to her children and pets.34

Reflections

Azra is concerned that abuse like what she recalls experiencing is continuing to happen to other children. She is aware of children currently in foster care who she believes are being sexually exploited or neglected, and that the care provider and the Department are aware of this but are not acting to protect the children.35 She stated: ‘It’s too late for me, but it shouldn’t be too late for them’.36

Azra proposed several ways that out of home care could be made safer for children, such as listening to the voices of adults who grew up in out of home care and developing strategies to help break the intergenerational cycle of out of home care:

Now, more than ever, we need to have the mentality of it takes a village to raise a child, and frankly it takes a whole lot more to heal a traumatized child. Most parents with traumatic childhoods similar to mine want to do better, want to be better, but simply lack the resources and know-how to do so. We can help them and we can certainly better support current carers who take in these children who often come with more issues than Vogue. We need to stop relying on that one social worker. Each child and family needs that village of support. This will prevent future children from falling through the cracks.37

Azra noted her experience of feeling devalued as a person, both in out of home care and when she sought recourse for the abuse against her. Her view is that the Government should take responsibility for past failures to protect children:

As an ex-ward of the state there has always been this stigma attached to me and to the many others like me. We are unfairly judged and completely dismissed because we are deemed ‘trouble’ and ‘liars’. This shame should never have been mine to bear, nor any other victim of past sexual abuse whilst under government care. That should be on the Government’s head. They should be ashamed and disgusted that they have sat back and allowed this to happen throughout the years knowing full well the damage it’s done.38

What we can learn

While Azra’s experiences in out of home care occurred before 2000, they have continuing relevance for understanding how we can better protect children from child sexual abuse in out of home care, including:

• the importance of adequately monitoring the safety of a child in out of home care and having other adults such as case workers who visit the child and with whom they can develop a relationship
• the vulnerability of children, particularly those who have no positive and appropriate relationships, to grooming and sexual abuse
• the need to ensure children in care receive sexuality and respectful relationship education, so they can recognise abuse for what it is
• the need for appropriate interviewing techniques following a disclosure, such as not interviewing children in the presence of the person who has had a complaint made about them
• the importance of ongoing support, including mental health and parenting support, for adults traumatised by their childhood experiences in out of home care.

Case example: Hudson39

Hudson (a pseudonym) was a small child when they came into Cassandra’s (a pseudonym) care in the late 2010s, following a number of previous foster care placements.40 Three years after entering her care, Cassandra discovered by chance that Hudson was Aboriginal.41

Cassandra told us that, at the time, there was a requirement for children to demonstrate Aboriginal heritage via specific documentation. She understood that although it was well known that Hudson was Aboriginal, Hudson’s parents had not been able to provide the necessary documents. The outcome was Hudson did not receive cultural support in care.42 Cassandra, herself an Aboriginal woman, described how she felt Hudson missed out on taking part in cultural programs due to this situation. She saw this as ‘systemic racism’ and a denial of Hudson’s right to ‘develop a positive sense of culture and identity’.43

Reflecting on the Child Safety Service, Cassandra referred to a ‘broken system’ and in her view, Hudson’s case:

… raises significant questions that must be answered, such as … how the failings of an individual Child Safety case worker can make or break a child’s ability to not just heal but to learn and engage and be supported and appropriately resourced to do so.44

What we can learn

Hudson’s case illustrates the importance of cultural identification for children in care and the importance of providing cultural supports.

Case example: Faye

The alleged abuse

Faye (a pseudonym) was placed into foster care with her sibling in the mid-1990s, when she was in late primary school.45 Faye recalled that her foster parents provided food and material comforts, and although they were strict, she experienced a stability and security she had not experienced before.46

After one of the foster parents’ adult sons moved back into the family home, Faye remembers case workers from the Department visiting and speaking with Faye and her sibling in the presence of their foster mother. She remembers these case workers asked if they wanted to stay in the home (which they did), although she does not remember them saying why they were asking. Faye told us she later found out that the son had been fired from his job for having a relationship with an underage person.47 In retrospect, Faye thinks the case workers likely visited in response to the allegation. She told us:

We hadn’t been told what had happened with [the son] and didn’t understand the implications or risk of him coming to live in the house with us. We were children. We should have been removed from the house by Children and Youth Services, at least until the allegation in relation to [the son] had been resolved.48

Faye said she and her sibling were left in the foster home, and case workers promised to visit regularly, but Faye said this didn’t happen.49

Faye explained that she was in early high school when the foster parents’ adult son gained Faye’s and her sibling’s trust by acting ‘cool’, bending the rules for them and taking their side. Faye now realises he was grooming them.50 Faye told us that his sexual abuse of her started with him pressing his genitals against her during play wrestling and trying to kiss her.51 Faye’s bedroom was located away from her foster parents’ bedroom, which she said made it possible for their son to sexually abuse her at night.52

Disclosure of the alleged abuse

Eventually, Faye said she told her sibling about the abuse and each agreed to never leave the other alone with their foster parent’s son.53 Faye said her sibling told their foster mother about the abuse. Faye said her foster mother laughed when Faye told her that the son had touched her on the vagina, and dismissed Faye’s experience, asking: ‘Is that all?’ Faye remembers that her foster father, however, seemed to believe Faye and her sibling, saying words to the effect of: ‘This has happened too many times. It can’t be a coincidence; they must be telling the truth’.54

Faye recalled being quickly removed by the Department after she disclosed the alleged abuse, but she was heartbroken to be separated from her sibling, who was left with the family. She was also distraught when many of her few possessions were lost in the move. Faye believed her foster mother withheld these possessions as punishment for alleging abuse by the son.55 Still, Faye missed her foster mother and wanted to see her again, but her foster mother did not attend an arranged meeting, and she never saw her again.56

The Department supported Faye to make a statement to police, but Faye did not feel able to proceed with charges at that time because of her sense of loyalty to her foster mother.57 She said she received specialist sexual assault counselling but did not feel comfortable and found it hard to open up.58

Reflections

Faye believes the Department failed to protect her from a known risk of sexual abuse, stating:

If there is any risk to a vulnerable child, that child should be removed from the environment. I accept that it would have been traumatising for them to remove me and my sibling from the home, but it would have been far less traumatising than the abuse I endured.

They had the opportunity to protect me, but they didn’t. They also failed to visit us more frequently, which they said they would. If they had have followed up I may have disclosed the abuse earlier.59

Although Faye was removed from the foster family, she said her sibling was left there, other children were placed there, and the family requested only girls be placed with them, despite their adult son being a known risk.60

What we can learn

We recognise that Faye was in care before 2000. However, Faye’s case highlights important issues of continuing relevance in out of home care which, if not followed, may expose children to an increased risk of sexual abuse:

• placing children’s safety at the centre of decision making—while it is important to take into account the wishes of a child, adults need to ensure they are taking responsibility for decisions about risks to safety
• ensuring all children in a placement are protected from risk of harm
• case workers regularly visiting children in care, to swiftly identify risks, build trust and enable disclosures61
• facilitating the security and support that children can gain from sibling relationships and having their own possessions.

Case example: Lucas62

Respite care

Lucas (a pseudonym), an Aboriginal man, and his partner Eleanor (a pseudonym), had a number of children in their care, including kinship care of several grandchildren.63 The family occasionally accessed weekend respite care to cope with the complex needs of the children in their care.

On one occasion, Lucas told us he could not meet the respite carers at their home before his grandchildren went there for respite care. But he recalled being told that Child Safety Service staff had inspected the respite carers’ home and assessed it as safe. Lucas said when he collected the children at the end of the weekend, he discovered an unsafe and filthy house. Lucas recalled that the children had not been adequately fed. When he arrived, Lucas said he saw an unknown man run away from the house and jump over the back fence. Lucas told us that it later transpired that neither Child Safety Service staff nor the non-government provider involved had inspected the house. Lucas stated that ‘you think they’re being cared for, and obviously they’re not’.64

Once home, Lucas said his granddaughter, Matilda (a pseudonym), who was under the age of five, started talking about being kicked by the respite carer as well as a man putting his penis in her vagina.65 Lucas told us that he and Eleanor eventually pieced together that several older male children had touched Matilda’s genitals, and the carer had become aware of this. Lucas said a forensic hospital examination confirmed that male DNA was found on a vaginal swab. Following the abuse, Lucas recalled that Matilda began having nightmares and exhibiting behavioural changes.66

Reflections

Lucas told us he was very concerned about the out of home care system: ‘The reality is, they’ve got no foster carers, they’ve got no emergency respite providers, they’ve got no respite providers’.67 He was concerned that respite carers may not be ‘doing it for the right reasons’ and that they were not sufficiently remunerated for the hard work performed: ‘If it were increased, I’m sure a lot more people would do it’.68

What we can learn

In addition to Lucas’ concerns about the system’s monitoring and support of respite carers, Lucas’ experience illustrates the importance of:

• processes and resources for assessing, training and monitoring out of home care providers—this includes ensuring respite carers have the capacity to provide the care required
• increasing the number of carers available to meet demand, particularly within suitable timeframes
• ensuring clarity of roles when both non-government agencies and the Department are involved in providing out of home care.

Case example: Orson and Ivan

Early experiences in care

Orson (a pseudonym) was taken into care while under the age of five and made subject to an order granting guardianship to the State until he turned 18.69 A few years later, concerns were raised that Orson had displayed aggression and sexualised behaviours towards other children. It was then decided that Orson should be placed with a foster family where he would be ‘the only child or the youngest child’.70

The alleged abuse

Orson’s new foster family already had an older child, Ivan (a pseudonym), in their care.71 The foster carers expressed concern that they might not be able to keep Orson safe because Ivan had previously displayed sexualised behaviours towards other children. The Child Safety Service decided this risk could be adequately managed.72

Almost three years later, the foster carers again told the Child Safety Service they were worried that Ivan might abuse Orson. Around a year later, Orson told his carers that Ivan had sexually abused him and then punched him in the face when he told other children.73 At this point, Orson’s carers began monitoring Ivan at night and attempting to keep both children safe by the children ‘never being unsupervised and not being permitted in the other’s bedroom’.74

The response

The foster carers immediately reported Orson’s allegations to his Child Safety Officer. The Department did not take any action. A later internal report noted that ‘this matter should have been notified and addressed when the concerns were [first] reported’.75

The foster carers took various measures to keep Orson safe, including taking him with them everywhere they went.76

Several months later, Orson also reported the alleged abuse to his teacher, who notified the Child Safety Service.77 Tasmania Police was informed and interviewed both children. Orson said that Ivan had raped him on multiple occasions since the start of the placement. The police did not pursue the matter due to insufficient evidence.78

The Child Safety Service referred the case to their Senior Quality Practice Advisor.79 A safety plan developed at this time stipulated that Orson and Ivan could stay in the same placement provided they were not left alone together.80 Orson’s service provider expressed concern that he ‘may be at risk’ under this arrangement, given that it relied heavily on the carers’ ongoing ability to provide ‘a very high level of supervision’.81 A Severe Abuse and Neglect report was finalised three months later. The report recommended an evaluation ‘to ensure the service is effectively meeting the identified need’ and noted that the current level of caregiver supervision was not sustainable.82 There is no record that any protective actions followed this report.

New allegations

Six months later, Orson said that Ivan had sexually abused him again when they had been left alone together for a short period.83 On this occasion, Tasmania Police sent the file to the Director of Public Prosecutions, and Ivan was charged with one count of rape.84 Ivan was temporarily and then permanently removed from the home following ‘grave concerns’ expressed by Orson’s service provider that he may be returned:

[Orson] now needs those responsible for his care to prioritise his need for safety and recovery … To place him in a position of needing to be exposed to [Ivan] in any way will diminish his ability to feel safe in his home and will further retraumatise him.85

What we can learn

Orson and Ivan’s case highlights the importance of the following in preventing sexual abuse and supporting children to heal:

• taking a preventative approach to placement decisions where known risks exist
• taking action to alleviate risk of harmful sexual behaviours in an out of home care placement when concerns are raised
• recognising that persistent and severe harmful sexual behaviour cannot be effectively managed by carer supervision and requires specialist treatment
• responding appropriately to disclosures of harmful sexual behaviours, addressing risks to all children and ensuring carers have the capacity to carry out the response
• the need to follow through on implementing recommendations when cases have been reviewed (such as those made in a Severe Abuse and Neglect report)
• providing trauma-informed responses and prioritising the safety and healing needs of a child who has experienced sexual violence.

Case example: Linda

Early experiences in care

Linda (a pseudonym) came into care at a young age with a ‘highly significant trauma history’ due to chronic abuse and neglect by her parents.86 Linda was placed in kinship care for a number of years, during which several notifications were made to the Child Safety Service about the carers’ tendency to perpetuate ‘trauma due to inadequate and inappropriate parenting responses’.87 The Child Safety Service sent a letter to the family outlining these issues but assessed that the risk did ‘not meet a threshold’ for intervention.88

When Linda was in her early teens, she began to self-harm and experience suicidal ideation.89 She was admitted to hospital several times.90 Linda’s relationship with her carers ultimately broke down and the Child Safety Service applied for guardianship of Linda until she was 18.91 Linda was placed with a residential care provider.92

The alleged abuse

In her mid-teens, Linda reported she had been taking nude photos of herself and sending them to men online who had requested them. In a statement to police, she disclosed she had also sent nude photos and videos to an older teenager who had expressed specific plans to ‘lure little kids home’ and ‘engage in sexual activities with them’.93 The Child Safety Service developed a safety plan for Linda that included extra monitoring, noting there was ‘some potential for [Linda] to engage in these activities again as monitoring adolescent behaviour online in a residential care placement is problematic’.94

Linda was receiving treatment for mental health issues at this time and was later referred to the Child and Adolescent Mental Health Service for further support.95

Sometime later, Linda attempted suicide and was admitted to hospital.96 She said she had been regularly leaving her placement to have unprotected sex with adult men she had met on social media, in exchange for illicit substances.97 The Child Safety Service made a referral to Tasmania Police and deemed the probability of further harm to Linda ‘highly likely’.98

Leaving care

Soon after, the residential care provider advised the Child Safety Service they could no longer adequately care for Linda because she was not supervised overnight and could leave the facility at any time.99 The following day, a healthcare provider told the Child Safety Service that Linda intended to run away.100 Child Safety Service staff asked Linda’s care provider to speak with her about this, and Linda ‘denied’ this was her intention.101 Five days later, Linda ran away.102

The residential care provider expressed feeling they had received ‘little’ or ‘no response regarding their concerned call’ to police about Linda going missing, prompting a meeting between Tasmania Police, the Child Safety Service and the provider.103 At the meeting, police first advised that this type of concern ‘would not be considered a priority’ and that they could not return Linda to her placement if she was unwilling to go, had not committed a crime and was not in immediate danger.104 But upon reflection, police agreed to start looking for Linda due to ‘significant concerns’ for her welfare and located her.105 The Child Safety Service referred Linda to another child welfare service ‘for assessment and case work to assist in building a safety network’.106

What we can learn

Linda’s case involved a number of missed opportunities to protect her from risks of harm. Her experience highlights the importance of:

• providing a traumatised child with a safe, supportive placement where their needs can be addressed therapeutically
• a residential care provider having the resources and capacity to protect the physical and online safety of a young person in their care
• the Child Safety Service taking a leadership role in protecting vulnerable young people at significant risk
• the need to identify probable future harm based on previous risk-taking behaviour, abuse and mental health issues
• Tasmania Police playing a role in intervening early when presented with concerns about a vulnerable young person and illegal acts occurring (including sexual abuse and providing illicit drugs to a child)—they can play a role in preventing or disrupting perpetration or holding abusers accountable.

Case example: Brett

Coming into care

Brett was taken into the care of the Child Safety Service when he was in his first year of high school in the late 2000s.107 At the time, he had moved from interstate to live with his father in Tasmania. He told us he generally felt loved and safe with his father.108 Brett said he and his father had been diagnosed with mental health conditions and had been having loud arguments for about two weeks when the Child Safety Service arrived at their house and took Brett into the care of the Department.109 Brett thought it would only be for a week, but the Child Safety Service applied for a six-month order.110

Once in out of home care, Brett lived in several different placements, including a rostered care house where one of the other residents had recently come out of youth detention and another was openly using illicit drugs.111 When he was taken into care, Brett told us he stopped going to school and never returned.112

Brett recalled being confused and upset about being taken away from his father, so he tried to run home whenever he was able.113

The alleged abuse

During weekend respite from his foster placement, Brett said he was sexually abused by an older boy who was also in care.114 The older boy told Brett not to tell anyone, but eventually Brett told his foster carer.115 Brett told us his foster carer did not believe him.116 Brett recalled he then told his father during a visit to his family. It was Brett’s father who contacted police.117 Brett explained that he tried to provide a statement to police about the sexual abuse, but he was too emotionally overwhelmed to finish it, so no further action was taken.118

Brett said he has accessed his Child Safety Service file, which included a record of his allegation of abuse by the older boy. Brett told us that the file indicated:

They didn’t believe I was sincere and it was just me trying to get out of another foster home. It said there would be an investigation but I was never spoken to.119

After the alleged abuse

As Brett was moved around placements, he continued to try to return to his father’s care, even when he was moved to the other end of the state.120 He said his desire to return to his father’s care to feel safe only increased after the alleged abuse: ‘That’s where I wanted to be, you know, I mean, that’s where—that’s where I felt safe, you know what I mean, that’s where I needed to be’.121

He said he also often slept rough because of the care he received in his placements, stating:

… at that time anywhere was better than the care houses, so occasionally I would just sleep on the street or occasionally I’d—occasionally I’d break into a car and just sleep in the back of it …122

Because he had no income, Brett turned to stealing to provide for himself and eventually decided to engage in a robbery to pay for an aeroplane ticket to the mainland.123 He was arrested and, within six months of being taken into care, he found himself remanded at Ashley Youth Detention Centre, where Brett said he was further abused.124 We discuss Brett’s experience in Ashley Youth Detention Centre in Chapter 11.

What we can learn

Brett’s experience highlights the importance of:

• the out of home care system providing a stable, safe, consistent placement—Brett found himself at greater risk on a number of levels once he entered care, leading him to stop formal education and eventually engage in criminal behaviour to try to ensure his own safety
• carers having the capacity to identify risks and believe children when they disclose child sexual abuse, and reporting such disclosures
• the Child Safety Service investigating an allegation of child sexual abuse of a child in care.

Case example: Addison125

My entire life … no one has ever been there to protect me.126

Coming into care

Before 2000, the mother of Addison (a pseudonym) was raised in out of home care and sexually abused in one of her foster homes.127 To her great distress, her children’s experiences mirrored her own: Addison and her siblings were exposed to family violence, neglect and emotional abuse from a young age, and were ultimately taken into out of home care in the mid-2010s. Addison had also been sexually abused by a family member.128

The alleged abuse

Addison’s experiences of sexual abuse did not end once she entered care. In one foster home she was abused by a ‘foster uncle’.129 In another, the abuse was perpetrated by her foster parents, Vanessa (a pseudonym) and Edmund (a pseudonym), and it was this abuse that most affected her.130 Before this placement, Addison was never taught about personal hygiene and did not know she could shower alone. Addison told us Vanessa and Edmund exploited this lack of knowledge to abuse Addison, ‘touching’ her and eventually raping her in the shower, describing this as ‘cleaning [her] insides’.131 Addison was unaware that this was not normal: ‘I was 12, I really didn’t know what that meant, I didn’t know that [Edmund] was having sex with me’.132 The abuse continued for more than two years. Addison recalled that Vanessa also regularly physically abused her.

Addison said she also experienced neglect and suffered the trauma of witnessing other children being sexually and physically abused in foster homes and ‘not knowing what to do’.133

The response

Addison tried to get help. She said she disclosed the abuse to a teacher at her school who immediately confronted Vanessa. This resulted in more severe physical punishments from Vanessa, ‘sometimes using knives’.134 Addison remembered also telling Department case workers of the abuse but said, time and time again, she was not believed: ‘They didn’t do anything about it’.135 She said one case worker witnessed her being physically abused by Vanessa but chose to ignore it. It was not until Addison and her sister ‘weren’t taking no for an answer’ that they were finally moved to other foster homes.136

When Addison said she was being abused by her ‘foster uncle’, Department staff told her to not worry about it because the abuser was already being investigated for another matter.137 Addison felt her concerns were not heard. She told us she felt the response of police was similarly dismissive; Addison reported the abuse two years ago but heard nothing afterwards. She told us that she believed these institutions were uninterested in taking action because she had a history of mental health problems and her family was well known to the Department ‘for all the wrong reasons’.138 Addison feared for her younger siblings who were still under the guardianship of the Department: ‘It’s like they’re blatantly ignoring us’.139

Journey in out of home care

The alleged abuse drastically affected Addison’s subsequent experiences in care. Finally, presented with a ‘good, loving family’, Addison recalled that she could not regulate her behaviours and the placement broke down.140 Addison remembered being moved to a group home where she felt her suicidal ideation was not managed in a trauma-informed way. For instance, Addison recalled that carers insisted on checking on her while she was showering, despite her abuse history and her requests for this not to occur. She said ‘it wasn’t until I didn’t just put myself but other people at risk’ that this ended.141

At 17, Addison said she was ‘thrown into the world’ by the Department without support or life skills for living independently.142 She continued to struggle with mental health issues and developed an addiction to alcohol as a result.

Everything that has happened has deteriorated my mental health to the point where it’s a struggle just being alive … [The age of] Ten is the first time I can remember trying to take my own life.143

Reflecting on the impact of the abuse and the lack of support afterwards, Addison noted that her worries were not those of a typical teenager. She emphasised that her life could have been different and much of the abuse prevented had someone listened to and supported her:

My worry should be college … I didn’t want my life to end up at this point, but due to everything and the fact that I never got any support, I ended up here with fears that someone much older should have … As soon as someone reports, do something ... You don’t know how long that has been going on, or what point it can get to … People need to start taking kids seriously.144

What we can learn

Addison’s case demonstrates the importance of:

• preventative education to help children to identify what is normal behaviour and what is abuse
• Department staff listening to, believing and acting on disclosures of child sexual abuse and physical abuse
• recognising the increased risk of subsequent abuse (even by other offenders) once sexual abuse has occurred
• understanding the risks of an ‘informal’ approach, such as speaking to the foster carers and not making an appropriate report
• providing adequate mental health support after disclosures of child sexual abuse where psychological difficulties are a factor
• ensuring carers have the resources and capacity to manage children’s behaviours in the context of a history of trauma
• supporting care leavers, ensuring they are prepared for living independently, particularly given a trauma history (contributed to through child sexual abuse while in care)
• police ensuring they follow up with a person reporting child sexual abuse.

1. Evidence from those with inside knowledge

We received numerous submissions about problems with the out of home care system from people who have worked in the Department or with non-government service providers. They expressed strikingly similar concerns about how the Department has structured, funded and operated out of home care in Tasmania. Many of these former employees had also worked in child protection interstate or overseas, allowing them to compare Tasmania’s out of home care system with systems elsewhere.

Most of the former employees, or those who had previous contact with the Department, who contacted us were willing to make a formal statement to our Inquiry, and some provided evidence at our hearings. However, a number expressed concern about the possibility of experiencing negative consequences from the Department for expressing critical views, including impacting any future engagement with the Department.145

One former senior employee described the Department as follows:

My sense is that the [out of home care] system is at best dysfunctional. It can also be an abusive system, capable of causing harm and trauma in its own right. Situated in the broader child safety system, it is perceived by many within the sector as a closed, defensive system, its approach crisis-driven and reactive. It is extremely difficult for those outside of the Department to gain information on how [the Child Safety Service] and [the out of home care service] operate or even its structure. I found there existed a culture of distrust by many children and young people, carers and its own workers towards the Department.146

1. Evidence from the Department

Publicly available information about the out of home care system and its measures to reduce and respond to child sexual abuse within out of home care has lacked detail. In keeping with our approach to all the institutions we inquired into, we relied heavily on the former Secretary of the Department of Communities, Michael Pervan, to speak about the Department’s operations. We also heard from the Executive Director of Children and Family Services, Claire Lovell, to assist our understanding of day-to-day decision making. Other members of the Department Executive, such as former Deputy Secretary for Children, Youth and Families, Mandy Clarke, were not asked by our Commission of Inquiry, nor offered by the State, to give evidence in relation to out of home care.

Despite the evidence we received about the evolution of the Department and areas that were under review, we remained unclear about key aspects of the Department’s functioning in the present. We drew on Secretary Pervan’s and Ms Lovell’s evidence as well as material from the Department’s Practice Manual, which guided staff practices and decision making relevant to out of home care. We outline our best understanding of the system in Chapter 7.

The challenges we confronted reflect the assertion of the former departmental employee quoted above—it is extremely difficult for those outside the Department to understand how the out of home care system is structured or operates.147 We further observed difficulties among those inside the Department to explain the system’s structures and operations.

1. The scale and nature of child sexual abuse in out of home care

There is little published information about the scale and nature of child sexual abuse in out of home care in Tasmania.

It is difficult to quantify the incidence of child sexual abuse in out of home care because such abuse appears to be under-reported.148 The best publicly available data is produced by the Australian Institute of Health and Welfare, which reports annually on the safety of Australian children in out of home care. Nationally, in 2020–21, 20.6 per cent of substantiated notifications of abuse or neglect of children in care related to child sexual abuse.149

Data on the Victorian Reportable Conduct Scheme published by that state’s Commission for Children and Young People indicated that, in 2020–21, 1,877 allegations of misconduct were made across all sectors that involved working with children (including out of home care), 396 (or 21 per cent) related to ‘sexual misconduct’ and 137 (or 7 per cent) related to ‘sexual offences’.150 In 2020–21, there were 49 allegations of sexual misconduct and 32 allegations of sexual offences in the out of home care sector.151 ‘Physical violence’ and ‘significant neglect of a child’ were reported more than any other type of abuse in out of home care in the same period.152

The 2014 final report of the Tasmanian Claims of Abuse in State Care Program provided some data about sexual abuse of children in care. This program operated in Tasmania from 2004 to 2013.153 Of a total of 541 claimants between 2011 and 2013, 394 were assessed as having experienced abuse (not limited to sexual abuse) while in care, and therefore, eligible for an ex gratia payment.154 Two hundred ‘accepted’ claims of sexual abuse while in care were made by 167 claimants (98 male and 69 female), which accounted for 21.4 per cent of overall accepted claims.155 Foster care was the setting of 128 (or 26.6 per cent) of all claims, although the period and nature of the abuse were not reported.156 Chapter 12 contains our recommendations about the Tasmanian Government’s response to allegations against out of home care staff and carers identified in the Tasmanian Claims of Abuse in State Care Program.

1. Risk notifications of child sexual abuse in out of home care

To help us get a comprehensive picture of the risk of child sexual abuse in care during the period of our Inquiry, we asked the Department to provide the following information:

• the number of children in out of home care who had risk notifications raised about possible sexual abuse while in care
• information on complaints, investigations or disciplinary action in relation to any allegations or incidents of sexual abuse that related to children in out of home care
• the number of departmental staff who had been stood down (had their employment suspended) over allegations against them in relation to sexual abuse of children in the out of home care system.157

In each case, we asked the Department to indicate, where records provided such information, what the Department’s response had been and the outcome of the concern or allegation. This information is discussed below.

Terminology regarding ‘concerns’

The Department uses several different terms relating to concerns about the sexual abuse of children in care. Some are used in a general sense, but others have a specific meaning in the context of out of home care. The following definitions explain how we use these terms in this volume.

Allegation or concern—we use these terms interchangeably to describe the situation where the Department has been made aware that a child in care may have been, or was at risk of being, sexually abused.

Care concern—a field in the Child Protection Information System that staff can select when recording an allegation or concern about a child in care being abused or neglected (refer to Chapter 9 for more about the care concern process).158

Notification or risk notification—a field in the Child Protection Information System that a Child Safety Officer can select when recording an allegation or concern about a child who may or may not already be in care.159

Incident—a field in the Child Protection Information System that a Child Safety Officer can select when recording an allegation or concern about a child, who may or may not already be in care.160

Investigation—in the context of the sexual abuse of children in care, we use this term primarily to refer to the care concern process applicable to serious or severe allegations of abuse or neglect. The Department sometimes uses the term as part of its response to a notification. We make it clear if the term is being used in this way.

Assessment—following a risk notification or an incident, the Child Safety Service uses this term to describe the process of seeking information about the risk to a child who may or may not already be in care.161

Initially, the Department provided a list of 439 instances where children in out of home care were the subject of a risk notification relating to child sexual abuse between 1 July 2013 and 30 June 2021.162 These risk notifications included concerns about children with harmful sexual behaviours. We understand the data was obtained from a broad search of the Child Protection Information System. It included a search of the system’s records of all children under a care and protection order or in out of home care and where the record mentioned the word ‘sexual’ in an ‘abuse type’ field or in the abuse type field of the person believed responsible.163 We understand this data reflects the number of concerns raised in relation to sexual abuse of children in out of home care—not the actual incidence of child sexual abuse in out of home care.

The Department reported the following information for each instance:

• the date of the notification
• the child’s date of birth
• the child’s age at the time of the notification
• the child’s gender
• the child’s Aboriginal status
• whether or not the child was identified as having disability
• the child’s postcode at the time of the alleged incident
• the date of the alleged incident
• the alleged abuser’s relationship to the child (for example, ‘Carer: Foster or Parents’)
• the alleged abuser’s gender, date of birth, whether or not they were identified as having a disability, and their Aboriginal status.

The Department cautioned that its dataset was missing some information and the incidence of concerns about sexual abuse for children in care may be under-reported.164 The Department also noted some limitations in the process of extracting this data from its Child Protection Information System, which may have adversely affected the quality of the data. In particular:

• The term ‘care concern’ was used as a search term but had not been consistently recorded by users when entering a risk notification into the system—a ‘care concern’ is a risk notification that a child in care is not being properly cared for and includes possible abuse or neglect of a child by a carer or someone associated with the household.
• The system allowed only one alleged person believed responsible to be recorded per incident, resulting in an undercounting of those believed responsible.
• The person believed responsible for many risk notifications was not recorded because the risk notification did not progress to assessment.165

1. Our analysis

Our analysis of the 439 risk notifications revealed the following:

• The risk notifications related to 299 children. Most children (68.6 per cent) were the subject of only one risk notification, but in a substantial number of cases (31.4 per cent), two or more risk notifications were made in relation to the same child. In one case, the Department had recorded eight separate instances of alleged abuse of the same female child.
• Numbers of risk notifications per year ranged from 35 to 81, with an average of 50, which equates to about one risk notification of possible sexual abuse against a child in care per week.
• While the ratio of female to male children in out of home care is about equal, 65.8 per cent of risk notifications were about the possible sexual abuse of a girl in care.166
• While 21 per cent of children in out of home care were identified as having disability, 27.3 per cent of risk notifications were about the possible sexual abuse of a child with disability.167
• Of children in out of home care, 37.4 per cent were identified as Aboriginal, although it is likely that the Aboriginal status of a child was not always accurately recorded (refer to Chapter 9). Just over one-quarter (27.8 per cent) of risk notifications concerned the possible sexual abuse of an Aboriginal child.168
• The relationship of most people believed responsible (64.5 per cent) to the child concerned was recorded as ‘not stated’, although in some cases a deeper reading of the material identified the relationship.
• Of the alleged abusers whose relationship with the child was stated:
  • 17.1 per cent were adults in the role of a foster, kinship or residential carer
  • 16.2 per cent were identified as a parent or relative of the child
  • 2.3 per cent were identified as other children in care.

The low proportion of alleged abuse from other children contrasts with expert evidence indicating that children in out of home care are more likely to experience sexual harm from other children, rather than an adult carer.169 It is possible this type of abuse is significantly under-reported or poorly recorded due to a lack of guidance to standardise identification and response (refer to Chapter 9). It is also possible some of the alleged abusers whose connection with the child was not recorded were other children or adults outside the care or family system who were engaged in child sexual exploitation.

Disputed figures

Secretary Pervan and Ms Lovell raised concerns about our analysis of the frequency of child sexual abuse risk notifications in out of home care.170

Ms Lovell told us the Department handled only ‘small numbers’ of care concerns—for instance, in 2021–22, she said the Department recorded 172 care concerns for children in care, which covered a broad range of concerns.171 Ms Lovell warned that these figures should be ‘interpreted with caution’ due to ‘inconsistent recording practices’.172 It is not clear whether the inconsistent recording practices were perceived to have inflated or under-estimated the actual extent of suspected child sexual abuse in care. Secretary Pervan explained that a manual review by Practice Managers identified that, in the 2020–21 year, 24 of the care concerns related to the possible sexual abuse of a child in care, nine of which were substantiated.173 And for the partial year from July 2021 to March 2022, Secretary Pervan stated there had been 13 notifications about the possible sexual abuse of children in care, five of which were substantiated.174

We understand that the data originally provided by the Department related to risk notifications in out of home care and not only those allegations categorised as care concerns in the Child Protection Information System. Ms Lovell explained that allegations that relate to carers, including in relation to child sexual abuse, are treated as care concerns. In contrast, allegations about abuse of children in care by people who are not carers are responded to using the standard ‘Child Safety assessment’.175 Therefore, we suspect the differences in figures have most likely arisen from the terms or categories used when recording concerns about children in care and during searches of the Department’s databases.

Secretary Pervan was concerned our Inquiry had misinterpreted the initial data the Department had provided to us, and had consequently overestimated the number of children who had been sexually abused in care.176 He said:

… it would seem that numbers relating to potential child sexual abuse in multiple contexts were reported by Counsel Assisting [during the out of home care hearing] as being the number of incidents of child sexual abuse in out of home care.177

We have considered Secretary Pervan’s concerns and conclude that our analysis of the data is sound for the following reasons.

Counsel Assisting used the term ‘439 allegations’ each time she referred to these numbers.178 In doing so, Counsel Assisting was pointing out that the Department was alerted to the possibility of sexual abuse of a child in care at the frequency of about one allegation per week, rather than one substantiated incident each week.179 Each of those 439 allegations required a response from the Department, even

if in the end they were not all substantiated. Failure to substantiate an allegation does not necessarily mean the alleged incident did not occur, but could mean that evidence was not sufficient to substantiate it or investigate it further.

As noted above, when the Department provided the original data on allegations, it cautioned that its dataset was missing some information due to limitations in its process for extracting data from the Child Protection Information System, and therefore, may under-report the true incidence of sexual abuse for children in care.180

As described in Section 4.1.2, we sampled 22 children’s cases, which involved 55 allegations from the 439 allegations provided (12.5 per cent of the allegations reported). The sample was deliberately selected to illustrate a diversity of child sexual abuse risks and characteristics of children in care in Tasmania.181 If the dataset contained irrelevant or false inclusions, we would have expected to see this reflected in our sample, but we did not. All 22 cases contained allegations of sexual abuse or concerns about the risk of sexual abuse for a child in care. We agree with Secretary Pervan’s subsequent decision to address problems in recording child sexual abuse by widening the scope of the type of concerns recorded as a notification on the Child Protection Information System to include:

• generating notifications for observations of behaviour that may indicate abuse that would previously have been embedded in case notes and incident reports
• raising separate notifications for any children who have been exposed to a person believed responsible, even when the allegation does not relate directly to those children
• maintaining a very low bar for substantiation not linked to the evidentiary threshold used by police or courts, which we take to be the balance of probabilities
• substantiating for children who were at risk of abuse, or even future abuse, due to being exposed to an unsafe person
• initiating new notifications and new assessments if the first assessment is called into question after receiving new information or a review.182

We consider that this broader view of child sexual abuse more accurately reflects contemporary understanding of the variety and complexity of risk concerns involving the sexual abuse of children in care.

Secretary Pervan was conscious that making these changes would increase the data on concerns about the sexual abuse of children in care:

Although the intentions of these changes is to improve safety for children, it will result in data indicating a higher number of notifications and substantiations. This may be misinterpreted as more children being at risk, or having experienced child sexual abuse.

Unintended consequences can include [an] incorrect narrative being published and discussed publicly, stigmatisation of children in out of home care and difficulty in recruiting staff and carers to a service which is viewed negatively.183

In our view, broadening the data collected to include all risks of sexual abuse would improve safety for children in care by revealing a more accurate picture of concerns. Reputational issues may be managed by ensuring the public narrative is correctly informed of the reason behind the change in data collection—to improve the safety and wellbeing of children in care.

1. Detailed analysis of 22 cases

To better understand the nature of the 439 allegations and the Government’s responses to them, we selected 20 children from the 299 children who were the subject of a concern about sexual abuse while in out of home care. Some of these were recorded as care concerns on the Child Protection Information System; others were recorded as notifications and some as incidents.184

The 20 children were selected to ensure our analysis included the experiences of children with a range of genders, Aboriginal status, disability status, geographical area, relationship of the alleged abuser to the child, and age of the child at the time of notification. We added the files of the two children who had the highest number of reported risk notifications—six and eight risk notifications respectively. The files we included were for children who were in care during the period from 2013 to 2021.

The Department provided 592 documents from the 22 children’s files relevant to the concerns, including notification records of care concerns, placement summaries, file notes of telephone conversations, emails, correspondence between departmental staff and carers or specialist therapy providers, Tasmania Police referrals, minutes of care team meetings, ‘investigation of serious abuse and neglect’ reports and file notes of home visits. We did not examine the child’s whole file. The Department produced a cover sheet for each child’s file that summarised the risk notifications identified and the Department’s process for selecting documents from the child’s file.

A review of the files revealed the following:

• All the children in the sample were either known, or strongly suspected, to have a history of sexual abuse before coming into the Department’s care. This is consistent with the known increased risk of sexual abuse for children in out of home care when they already have that history.185
• Multiple risk notifications of abuse or neglect in relation to a child in care was the norm in our sample. Across the 22 files reviewed, there were 55 risk notifications and most cases involved risk notifications of more than one form of child sexual abuse while in out of home care. The most common presentation was a combination of risk notifications relating to harmful sexual behaviours and abuse by an adult, or adults, whether a carer or a person outside the care environment.
• Risk notifications about harmful sexual behaviours were common. Eleven children were alleged to have either engaged in harmful sexual behaviours themselves, or experienced such behaviour from another child or children in care. Most of these children were alleged to have engaged in multiple instances of harmful sexual behaviours and/or been subject to more than one incident.
• Risk notifications about child sexual exploitation were represented. Four children in the sample were alleged to have been groomed or sexually exploited by multiple adults outside the care or family system, although some of the ‘persons believed responsible’ were recorded in the initial dataset as ‘unstated’. All four of these children were female and three had a known intellectual disability. One of the risk notifications involved producing online child exploitation material and attempts to enlist the child to recruit other, very young children to be similarly exploited.
• Risk notifications of abuse by carers or residential care workers were also common. The files of 11 children contained risk notifications about a current or previous foster, residential or kinship carer.
• Sometimes risk notifications were recorded for a child when there was concern about possible exposure to risk, rather than a direct allegation. Three of the children had a risk notification recorded as a result of alleged sexual abuse of a sibling or another child in the same placement, but no allegation had been made a that time about the child in question.
• Children in out of home care were at risk of sexual abuse from a variety of sources. One risk notification involved a teacher allegedly grooming a child in care, another involved boundary breaches by a departmental employee, four risk notifications related to biological family members sexually abusing or grooming children during visitation, and one involved the alleged sexual assault of a girl by her same-aged boyfriend.
• The rate of criminal conviction was low. Of the 55 risk notifications recorded in the files, only two risk notifications were recorded as resulting in a criminal conviction. While police were involved in investigating many of the risk notifications and took statements, it was common for matters not to proceed to charges because the child did not want to give evidence.

These themes are similar to those identified by the National Royal Commission. They also reflect anecdotal evidence we heard at our targeted consultation with out of home care providers.

The Department’s responses

Some aspects of the Department’s responses to risk notifications of sexual abuse concerning children in out of home care appeared reasonable. Although it was not always clear what care concern process was followed (refer to Chapter 9 for more about care concern processes), overall there was evidence that departmental and out of home care staff undertook some form of investigation or assessment of each concern.

Positively, there was consistent evidence across the files that Tasmania Police were involved in investigating risk notifications of sexual abuse of children in out of home care. This evidence included formal referrals to and from police, and ongoing liaison about risk notifications in emails and file notes.

While there was evidence of some departmental staff and police describing children who were allegedly being sexually exploited outside the placement as engaging in ‘risk taking behaviours’, the Department and non-government out of home care providers appeared to regularly approach Tasmania Police for support with these concerns.186 In addition to trying to educate the children involved about self-protective behaviours, staff had documented some proactive attempts to intervene, such as taking out a restraining order against an alleged abuser, police attending premises to retrieve a child, and staying in contact with the child.187 We discuss the Department’s response to child sexual exploitation in Chapter 9.

System and practice failures

The file reviews also revealed system and practice failures that may have adversely affected the Department’s capacity to predict an increased risk of sexual abuse for a child in out of home care and therefore, to act protectively. These included the following:

• We observed inconsistent recording of Aboriginal status between documents within children’s records, leading to uncertainty about a child’s Aboriginal status. Without clarity of Aboriginal status, it would be difficult to know if cultural support was needed for a child.
• For those children who were identified as Aboriginal, we saw limited evidence in the records of the presence of cultural support plans or engagement in cultural support activities. Refer to Chapter 9 for a discussion of the need for cultural engagement for Aboriginal children in care and its centrality in protecting children from sexual abuse and facilitating disclosure.
• It was difficult to identify children with disability unless we read each file note in detail and again, this information was recorded inconsistently. Rarely did a child’s disability feature as a vulnerability factor in the risk assessment section of a notification or assessment record. Our impression was that it would be difficult for staff accessing these records to identify the nature of the child’s disability (and consequently, the support they might need) and to consider that information when assessing risk to a child, specifically in relation to the risk of child sexual abuse. In Chapter 9, we outline the importance of a clear understanding of each child’s individual needs, including their disability support needs, to acting protectively.
• The review identified very few case and care plans among the documents provided. It is possible these documents were omitted during the Department’s process of compiling the files for us. However, the absence of these plans is also consistent with concerns raised by witnesses such as Andrea Sturges from Kennerley Children’s Services, who reported that less than 5 per cent of the 105 children in Kennerley’s care had current case and care plans.188 (Refer to Chapter 9 for a discussion of care plans.)
• The notes made by departmental staff often referred to following the ‘care concern process’, but it was not always clear which process was being followed: the ‘quality of care concern’ process or the more serious ‘investigation of serious abuse and neglect’ process. On occasion, notes referred to risk notifications being managed through other processes such as ‘case consultation’ or an ‘incident response review’ or a matter being ‘handled in Assessment’. This use of different and unclear language made it difficult to assess what had occurred. We examine the care concern process in Chapter 9.
• The risk assessment section of the notification record was frequently not updated with current information to support the risk assessment and decision made, and often appeared to have been cut and pasted from previous notification records. In one instance, the risk assessment section content referred to the child being seven years of age and living with her parents, when she was in fact aged 17 and living in a residential care setting, and had been in care since she was seven.
• Staff regularly used the term ‘self-selected’ in their notes to describe why children and young people in care were not living in their placement. This confirmed concerns raised by others who work regularly with the Department of a pervasive practice among departmental staff of deferring responsibility to children to decide where they live rather than viewing them as missing from placement (refer to Chapter 9). This is particularly concerning in light of the National Royal Commission’s observations on groomed compliance of children experiencing sexual exploitation.

Harmful sexual behaviours

In relation to risk notifications about harmful sexual behaviours between children in out of home care, we observed the following from the files:

• The nature of alleged harmful sexual behaviours ranged from developmentally inappropriate to coercive or violent sexual behaviours (refer to Chapter 21 for more on the continuum of harmful sexual behaviours).
• Positively, there was strong evidence of departmental staff appropriately referring children involved in alleged incidents to specialist support and intervention agencies, such as the Australian Childhood Foundation, Laurel House or the Sexual Assault Support Service.
• All children who were believed to have displayed or been subject to harmful sexual behaviours, were known to have been involved in sexualised or harmful sexual behaviours before being moved to the placement where the alleged incidents took place. We were concerned the Department may not have sufficiently considered the known risk factor of a history of harmful sexual behaviours when making placement decisions.
• ‘Adult supervision’ was a strategy departmental staff relied on regularly to manage the risk of harmful sexual behaviours between children in out of home care. We are concerned this approach is not practically achievable in a home or residential care setting (refer to Chapter 9 for a discussion of managing harmful sexual behaviours in out of home care).
• There was no evidence that departmental staff referred to any harmful sexual behaviours framework or policy documents when assessing and managing the risk of harmful sexual behaviours for a child.
• The Department’s response to alleged incidents of harmful sexual behaviours was varied—in some instances, the Department immediately removed one of the children involved from the placement, and in others, it left the children in the placement with increased supervision from the carers. It was not apparent that the different responses were determined by the nature of the behaviour.
• Many of the children involved in an incident of harmful sexual behaviour had an intellectual disability. There was evidence on the files that when the child who displayed the harmful sexual behaviour had an intellectual disability, some departmental staff downplayed the impact of the behaviour on the other child.

1. The Department’s response to incidents and allegations

We asked the Department to provide information about ‘complaints made, or investigations, or disciplinary action’ in response to any allegations or incidents of child sexual abuse in out of home care, from 1 January 2000 to 9 March 2022. We asked for:

• the names of the person reporting the incident, the alleged victim-survivor and the alleged abuser
• the dates of the alleged incident and when the allegation was raised
• a summary of the allegation
• who in the Department was involved in responding to the allegation or incident
• any actions taken by the Department such as reporting the incident to police or regulatory agencies
• the outcome of the allegation.189

We expected some overlap between the data already provided for 2013 to 2021, but this request differed from the initial data request in that we were asking primarily about the alleged abusers and the Department’s response to them. The data the Department provided reflected this focus. It drew from the Children’s Advice and Referral Line Digital Interface, the Child Protection Information System (from 2008 onwards), a manual review of documents produced for the Joint Review Team (a recent cross-jurisdictional document review led by Tasmania Police; refer to Chapter 16) and the Abuse in State Care Support Service (refer to Chapter 11). We understand the search of the documents focused on alleged abusers (the Department records these as ‘persons believed responsible’) and the Department’s response to alleged abusers.

The Department told us minimal information was recorded for cases before the Child Protection Information System was introduced in 2008, and staff have only recently begun recording the persons believed responsible more consistently in the database.190 The Department acknowledged a limitation of its data system for this purpose is that it is naturally ‘child-centric’, which means that relatively little information about other people in a child’s life is captured on the child’s record.191

Given this context, we expect the records the Department provided to us are not comprehensive in identifying those believed responsible for abuse in out of home care and that the data extracted underestimates the number of allegations of sexual abuse in out of home care.

Consequently, the Department listed 284 allegations, considerably fewer than the 439 instances they identified when the focus was on children’s records rather than persons believed responsible.192

Acknowledging the data limitations, we reviewed this second list to understand how the Department responded to alleged sexual abuse of a child in care by an adult. After removing allegations of harmful sexual behaviours, we focused on 106 allegations concerning adults believed responsible and observed that:

• most allegations were against foster or kinship carers, or an associate of the carers
• very few allegations related to child sexual exploitation
• allegations were recorded for 72 different persons believed responsible
• concerningly, very few outcomes and actions resulting from the allegations were provided
• eighteen of the persons believed responsible had multiple allegations against them
• the care concern process was reported as having been initiated in 25–30 per cent of cases
• police referrals were recorded in about 40 per cent of cases.193

1. Staff suspensions and terminations following allegations of abuse

The Department has provided us with a list of suspensions between January 2000 and 2023 in relation to out of home care—this includes reference to four suspensions.194 We received information from Secretary Pervan about one other suspension that was not included in the Department’s list.195 The four cases about which we received information from the Department are described in deidentified form below.

1. Suspension 1

In the late 2000s, a male child protection worker was suspended for alleged breaches of sections 9(2) and (14) of the State Service Act 2000. It was alleged he had sent ‘inappropriate texts’ to one of the teenagers he was case-managing and to a ‘vulnerable young woman’ over the age of 18. The terms of his suspension are unknown, but an Employment Direction No. 5—Breach of Code of Conduct investigation determined he had breached sections 9(1), (3) and (14) of the Act. The Department referred the matter to Tasmania Police, but no charges were laid. The man’s employment was terminated.196

The Department could not identify the date it was notified of the allegations attached to this suspension. The Department’s records indicated two dates of suspension, six months apart. The Department therefore, could not say how long it had taken to suspend the employee after receiving the allegations. The man’s employment was terminated five months after the Employment Direction No. 5—Breach of Code of Conduct investigation started.197

We received additional information that the man had been accused of sending inappropriate or sexualised texts to other children in care during his employment with the Department. The Department had conducted two previous Employment Direction No. 5—Breach of Code of Conduct investigations, but it was not clear if the employee was suspended during these investigations. In these instances, the Department had issued ‘lawful and reasonable directives’ to desist after conducting investigations.198

1. Suspension 2

In the early 2000s, the Department became aware of allegations about a male departmental employee who worked as a carer. The allegations were that he was ‘having a sexual relationship with a [child aged less than 18 years] under the guardianship of the Secretary’. Tasmania Police charged him with sexual abuse charges, including four counts of ‘sexual intercourse with a young person’. According to the Department, ‘at least 166 days’ elapsed between the date police charged the man—when the Department became aware of the allegations—and the date he was suspended. The Department did not provide an explanation for the delay in suspending the man, nor did it describe the terms of his suspension or the outcome of the matter.199

1. Suspension 3

A long-serving male Child Safety Officer was suspended after the start of our Commission of Inquiry. The Department instigated an Employment Direction No. 5—Breach of Code of Conduct investigation in relation to a longstanding pattern of boundary breaches involving children in the care of the Department. It was alleged the employee accessed the files of children in out of home care who were no longer under his management, interviewed children under his management at his home, and transported children in care in his personal vehicle. The Department advised that he had been given ‘lawful and reasonable directives’ and reminder letters of these directives, but his behaviour continued.200 At the time of writing, we are unaware of the outcome of this matter.

1. Suspension 4

A male support worker employed by the Department was stood down after the start of our Commission of Inquiry. The Department instigated an Employment Direction No. 5—Breach of Code of Conduct investigation into alleged unsafe practices by this worker, namely transporting children in care in an unsafe manner. The Department acknowledged it was aware of other concerns about the worker over a longer period, which had not resulted in an investigation. These concerns were:

• the worker being charged in the early 2000s with possession of child exploitation material that did not proceed to a conviction
• a conflict of interest arising from a personal relationship with a foster carer
• taking longer than was necessary to transport children in care, raising concerns about his activities with those children
• the negative response of a child in care to being transported by the worker.201

The Department advised us it had notified the Registrar of the Registration to Work with Vulnerable People Scheme of these concerns. Subsequently we received documentation indicating that the worker’s registration to work with vulnerable people had been cancelled.202

These four cases constitute very few staff being suspended or terminated over more than 20 years. Because of poor record keeping, it is difficult to determine whether there has been more disciplinary action than that reported to us, or whether the Department has been slow to take action against staff for concerning behaviour.

1. Overview of systemic problems

Through our review of the information received by us—from children in care, case file reviews, from those working within and with the out of home care system, previous reviews and inquiries, and the documents and policies we have reviewed—we have identified a number of systemic problems with Tasmania’s out of home care system that should be addressed to better protect children in care from the risks of child sexual abuse, and improve the response when abuse does occur. We elaborate on these problems in more detail in Chapter 9, where we discuss our reasoning for our recommendations for the way forward. However, in summary, these problems include:

• challenges in adopting measures to prevent child sexual abuse, including ensuring appropriate placements of children
• difficulties consistently putting in place risk mitigation strategies when risks are identified, such as providing early treatment for serious and concerning harmful sexual behaviours
• not consistently addressing the trauma children have experienced before or during their out of home care experience, increasing their risk of child sexual abuse or reducing their confidence in disclosing such abuse
• not consistently addressing the cultural needs of Aboriginal children, increasing their risk of child sexual abuse or reducing their confidence in disclosing such abuse
• insufficient supports for staff and carers to manage risks of child sexual abuse, or respond appropriately when it occurs
• inconsistent and uneven responses when children disclose child sexual abuse while in care.

We consider that these problems are, at least partially, a result of a system under pressure. They need to be addressed through changes to the systems and processes of out of home care generally, rather than tweaks to the system. In Chapter 9, we consider in detail various aspects of the out of home care system, and explain our recommendations for keeping children in care safe and for improving departmental responses to child sexual abuse.