Under Part 5A of the Community Services (Complaints, Reviews and Monitoring) Act 1993, the NSW Ombudsman convenes and supports the NSW Child Death Review Team (CDRT).
The NSW Child Death Review team (CDRT) is established under Part 5A of the Community Services (Complaints, Reviews and Monitoring) Act 1993. The CDRT reviews and maintains a register of the deaths of all children aged from birth to 17 years and analyses this data to identify trends and make recommendations to reduce the risk of preventable deaths of children in the future. The CDRT includes experts in healthcare, child development, child protection and research, as well as representatives of key government agencies (see below). The NSW Ombudsman is the Convenor of the CDRT and NSW Ombudsman staff provide support to the CDRT, including by coordinating and undertaking research and completing all reviews.
Read the CDRT’s Strategic Priorities Plan 2022-25.
Read the Biennial report of the deaths of children in New South Wales: 2020 and 2021.
Read the CDRT Annual Report 2023-2024.
Role of the CDRT
The CDRT:
- maintains a register of child deaths in NSW
- classifies deaths in the register according to cause, demographic criteria and other factors
- analyses the register to identify patterns and trends
- undertakes research to prevent or reduce the likelihood of child deaths, guided by the CDRT Research Framework
- makes recommendations to government and community organisations about legislation, policies, practices and services
- reports to the NSW Parliament on its work and activities.
Read the CDRT Charter and Code of Conduct.
CDRT members
Ex officio members
Mr Paul Miller PSM, (Convenor), NSW Ombudsman
Ms Monica Wolf - Community Services Commissioner / Chief Deputy Ombudsman
Ms Zoe Robinson - NSW Advocate for Children and Young People
Agency representatives
Alison Sweep - Director Engagement and Family Support, Department of Communities and Justice
Amy Vincent-Pennisi – Coronial Information and Support Program Coordinator, NSW State Coroner
Anne Reddie- Director, Child Wellbeing and Mental Health Services, Student Support and Specialist Programs, Department of Education
Danny Doherty APM, Detective Superintendent- Commander, Homicide Squad, State Crime Command, NSW Police Force
Dr Helen Goodwin – Chief Paediatrician/Senior Clinical Advisor Paediatrics, NSW Health; Senior Staff Specialist Paediatrician, Royal North Shore Hospital
Sarah Bramwell - Director, Practice Learning, Office of the Senior Practitioner, Department of Communities and Justice
Vanessa Chan - Director, Criminal Law Specialist, Department of Communities and Justice
Independent members
Dr Bronwyn Gould AM - General Practitioner
Professor Ilan Katz - Professor Social Policy Research Centre, University of NSW
Kathleen Clapham AM, Professor - Professor (Indigenous Health), School of Medical, Indigenous and Health Sciences; Director, Ngarruwan Ngadju First Peoples Health and Wellbeing Research Centre, University of Wollongong
Dr Lorraine Du Toit-Prinsloo - Chief Forensic Pathologist and Clinical Director, Forensic Medicine Newcastle, Forensic & Analytical Science Service, NSW Health Pathology
Dr Luciano Dalla-Pozza - Head of Department (Cancer Centre for Children), Senior Staff Specialist (Paediatric Oncology), The Children’s Hospital at Westmead
Dr Matthew O’Meara - Senior Staff Specialist Paediatric Emergency Medicine, Sydney Children’s Hospital Randwick
Ngiare Brown, Professor - Chancellor, James Cook University; Chair, National Mental Health Commission Advisory Board; Director and Program Manager, Ngaoara Child and Adolescent Wellbeing; Executive Manager Research and Senior Public Health Medical Officer, National Aboriginal Community Controlled Health Organisation; Professor of Indigenous Health and Education, University of Wollongong
Dr Susan Adams - Senior Staff Specialist, General Paediatric Surgeon and Head of Vascular Birthmarks Service, Sydney Children’s Hospital; Associate Professor, School of Women’s and Children’s Health, University of New South Wales
Dr Susan Arbuckle - Paediatric/Perinatal pathologist, The Children's Hospital at Westmead
Register of Child Deaths
Under the Community Services (Complaints, Review and Monitoring) Act 1993, the NSW Ombudsman maintains a Register of Child Deaths (the Register) on behalf of the CDRT that includes information relating to the deaths of all children and young people aged under 18 in NSW.
The Register contains over 16,000 records dating from 1996 of children aged 0-17 years. The Register consists of three databases, including a legacy database of deaths that occurred in 1996-2013, ‘DRS’ database of deaths from 2014-2017, and ‘RCD’ database of deaths from 2018 to present. All deaths are reported according to the year a death occurred, not the year a death was registered.
Process of recording deaths
- The NSW Ombudsman is routinely notified of the deaths of all children aged 0-17 years in NSW by the NSW Registry of Births Deaths and Marriages (BDM). Relevant information for registering, classifying, analysing, and reporting on deaths is then sourced from records provided by government and non-government agencies and service providers that came into contact with the child or young person, including NSW Health, Department of Education, Department of Communities and Justice, NSW Police, the Coroner, and family support/early intervention/out of home care/disability support services.
- All records relating to the death of a child or young person are reviewed by NSW Ombudsman staff and used to populate a wide range of fields in the Register. In some cases, a detailed narrative of the events leading up to the death, and the circumstances of the death itself, are also recorded.
Data capture and coding
- At a minimum, the following data fields are captured for all deaths: date and location of death, key demographic data, cause of death, family details, and any child protection history for the child and/or sibling.
- The following data fields may also be captured depending on the cause of death: social/health/behavioural factors, autopsy and toxicology results, whether the death was subject to criminal investigation, details of the death (what occurred and proximal factors), and agencies involved with the child.
- A data dictionary is used by staff to ensure that data is collected and classified consistently (e.g. identification of Aboriginal and Torres Strait Islander children and young people).
- The death of each child or young person is coded with cause of death using ICD-10-AM (the Australian version of the coding system overseen by the World Health Organization).
Use of the data
- The data held in the Register is used to identify trends and patterns, to inform public reporting and to support research. A key function of the CDRT, as outlined in the Community Services (Complaints, Review and Monitoring) Act 1993, is to make recommendations based on the evidence relating to legislation, policies, practices, and services for implementation by government and non-government agencies and the community to prevent or reduce the likelihood of child deaths. ·
- The Community Services (Complaints, Review and Monitoring) Act 1993 prohibits the sharing of data and information to others except under specific circumstances. These circumstances include when it is being used for research to help prevent child deaths, if an agreement is in place with another organisation that has a similar function, if it is for the purpose of exercising a function of the CDRT, to specific organisations with interest in reviewable deaths, or where the NSW Ombudsman believes it’s appropriate.1
1 s 34L(1)(a), s 34L(1)(b), s 34L(1)(c)(vi), s 34D(3), 39(1) and 39(2) of the Community Services (Complaints, Review and Monitoring) Act (CS-CRAMA)
