An investigation into the abuse and neglect of two severely disabled Queensland brothers over a 20-year period has found health staff were not adequately trained to report and escalate child abuse concerns, with ineffective government systems exposing vulnerable children to further harm.
The report, the third in a series by the Queensland Ombudsman examining the ability of public sector agencies to prevent harm to children with disabilities, was commissioned in response to a case of severe abuse and neglect involving two Queensland children, referred to as Kaleb and Jonathon.
The brothers – who had lived with significant global development delay, intellectual disability and autism, and had limited verbal communication – were found malnourished and naked in a bare room with the door handles removed in May 2020 after emergency services were called to the house where they lived with their father. He was found dead.
The case was the subject of a public hearing as part of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability in 2023, with the Queensland Ombudsman later tasked with investigating public sector agencies that had interactions with Kaleb and Jonathon.
The report published on Tuesday focused on the brothers’ interactions with Queensland Health between 2000 and 2020.
It found that while Queensland Health had developed protocols to help staff identify and respond to child abuse and neglect, staff needed clearer guidance and consistent information on how to report child protection concerns.
It also recommended changes to information management systems to allow staff to easily cross-check concerns; regular audits to identify at-risk children who fail to attend health appointments; and the possibility of mandating the use of Child Safety’s Child Protection Guide.
Kaleb and Jonathon were born in Queensland Health hospitals in 2000 and 2003 respectively.
Concerns about Kaleb’s safety and wellbeing were reported to Child Safety shortly after his birth, and he was placed in foster care for “significant periods” during the first three years of his life.
Staff made similar reports about both children after Jonathon’s birth in 2003.
The boys were diagnosed with developmental delay and intellectual disability as young children, and received “considerable daily care and support needs”, and occasional specialist healthcare throughout their younger years.
In 2005, Queensland Health staff reported concerns after both children missed several health appointments, and expressed fears that the brothers may be experiencing neglect. These were found to be “substantiated”.
Over the next 10 years, the brothers missed multiple specialist medical appointments, which was not followed up by Queensland Health, despite previous concerns about their wellbeing. No further reports were made to Child Safety either.
The royal commission was told their non-attendance at medical appointments was part of a body of evidence that they experienced chronic neglect in their father’s care.
Another issue identified by the ombudsman was Queensland Health’s use of both electronic and paper-based files, which it said hindered staff from being able to identify patterns of harm.
“Effective information sharing between Child Safety and agencies like Queensland Health is crucial for identifying and supporting children in need of protection,” Queensland Ombudsman Anthony Reilly wrote.
Queensland Health director-general Dr David Rosengren said many of the ombudsman’s recommendations will be considered through “established policy and procedure review cycles”, with work under way to digitise health records and consider auditing at-risk children who miss scheduled outpatient appointments.
“Queensland Health will continue working closely with Child Safety and other partners to strengthen responses to the health needs of vulnerable children, young people and families engaged with Queensland’s child protection and public health systems,” Rosengren said.
In 2023, Queensland’s child safety minister apologised to Kaleb and Jonathon for the decades of violence, abuse and neglect they suffered under their father’s care.
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