THE COMMISSIONER: Please read the terms of reference.
MR VONGPHAKDI: Commissions of Inquiry Order (No. 1) 2025:
Under the provisions of the Commissions of Inquiry Act 1950, the Governor in Council hereby appoints Paul Elias Anastassiou KC as Commissioner from 1 July 2025 to make full and careful inquiry in an open and independent manner with respect to:
a. Reforming the residential care system: investigate models of care and the factors contributing to the growth and reliance on a billion‑dollar residential care sector, including:
i. Analyse residential care in the historical context since the Carmody Inquiry and the increases in the use of individual placement support services and residential care.
ii. Investigate contemporary models around the world for the delivery of residential care, with a focus on best practice to support children who are more at risk.
iii. Consider what constitutes quality of care in both licensed and unlicensed providers, including from the perspectives of children and young people.
iv. Analyse contemporary models for licensing care providers.
v. Investigate the current state of the market of residential care providers operating under not‑for‑profit and for‑profit models.
vi. Analyse previous Queensland Government procurement and contracting process for residential care providers to identify opportunities to improve efficiency, transparency and accountability.
b. Fixing a broken system: reviewing the effectiveness of Queensland's child safety system to keep children safe, including:
i. The practices and procedures of the department, specifically focusing on investigation, assessment, casework and reunification.
ii. Tertiary child protection interventions, including adoption, case management, service standards and decision‑making frameworks.
iii. The management, training, supervision and ongoing oversight of casework within the department.
iv. Departmental delivery structures including organisational culture, management structures and operations of regional service delivery (in each region).
v. The ability for information sharing across relevant agencies.
iv. Review departmental governance, including financial, procurement and contracting delegations, and structures to manage conflict of interest and reporting.
vii. Whether departmental frontline staff are resourced and supported to do their work and outline any deficiencies in the level of support, decision‑making frameworks, caseloads, and court and tribunal processes.
viii. Investigate the role of the privacy provisions of the Child Protection Act 1999; and whether the provisions hamper transparency around system failures.
ix. Consider how to facilitate aculture of transparent reporting in the context of Coldrake Review.
x. Investigate the role of third parties including peak bodies and oversight bodies and their interaction with the department and minister in pursuit of system improvement, and any issues relating to funding, reporting and their role in the media to ensure integrity and accountability.
xi. Evaluate ministerial accountability of the child safety system since the Carmody Inquiry and the role the minister has played in the performance of the department.
xii. Review the effectiveness of the existing complaints process.
c. Safer children: failures both systemic and policy that have impeded the ability of the department responsible for the Child Safety Portfolio (the department) to provide support to families and protection to children at risk of harm in Queensland; and, in particular, to use case studies to:
i. Identify failures of the department to intervene or to protect children, with a summary of findings and recommendations of collated coronial inquiries since the Carmody Inquiry and the establishment of the Child Death Review Board.
ii. Review the decline in foster care and treatment of foster carers by the department and by service providers contracted by the department.
iii. Review child placement breakdowns, with a focus on cases with more than four placements in a child's life.
iv. Investigate the contributing factors for breakdown of placements due to lack of support for kinship carers.
d. Safer communities: evaluate the effectiveness of the department as a corporate parent and whether it is able to meet community expectations around parenting.
i. Investigate through case studies children subject to dual youth justice and child protection orders or children under the guardianship of the department who have committed crimes and fall within the "Making Queensland Safer Laws" category and determine the failures of policy, process and practice that contributed to these children choosing a life of crime.
e. Reviewing Queensland legislation about the protection of children, including the Child Protection Act 1999, and Adoption Act 2009.
f. Any other matter relevant to the Inquiry.
And directs that the Commissioner make full and faithful report on the aforesaid subject matter of the Inquiry, including an executive summary.
And makes recommendations that the Commissioner considers appropriate and feasible on:
a. Reforming the residential care system: which existing models of residential care best support children who have high complex needs (particularly those with a disability) and Aboriginal and Torres Strait Islander children and appropriate market structures to best deliver those models.
b. Fixing a broken system: the implementation and appropriateness of child safety practices; departmental structure, governance and culture; the adequacy and effectiveness of current training programs for child safety staff; the extent to which leadership structures support accountability in the protection of children; ministerial engagement and accountability; appropriate frontline resourcing; and third parties including peak bodies and oversight bodies.
c. Fixing a broken system: design and implementation plan for a new independent complaints escalation review process to escalate serious concerns about complex cases and restore critical support for families and carers.
d. Safer children: system designed to support and facilitate foster care, kinship care and adoption in a modern best practice setting.
e. Safer communities: new models of care ensuring children are providing an opportunity for intervention and rehabilitation and that escalating risk or behaviours are managed in line with community safety expectations.
f. Any reforms to ensure that Queensland's child protection system achieves the best possible outcomes to protect children and support families.
g. Any legislative reforms required.
And directs that the report be transmitted to the Honourable Premier and Minister for Veterans, the Honourable the Attorney‑General and Minister for Justice and Minister for Integrity, and the Honourable the Minister for Families, Seniors and Disability Services and the Minister for Child Safety and the Prevention of Domestic and Family Violence.
And directs that the final report be provided to Government by 30 November 2026, And that the Commissioner will determine whether any interim reports are to be provided before that date.
Pursuant to section 4(2) of the Commissions of Inquiry Act 1950, it is declared that all the provisions of the Commissions of Inquiry Act 1950 shall be applicable for the purposes of this Inquiry, except for section 19C (Authority to use listening devices).
The Commission may receive submissions from relevant individuals and entities and hold public and private hearings in such a manner and in such locations as determined by the Commissioner, as appropriate and convenient, in a way that promotes transparency.
THE COMMISSIONER: I commence by acknowledging the traditional owners of the land on which we meet, the lands of the Yuggera and Turrbal people and I pay my respects to their Elders, past, present and emerging.
I welcome all present today and all those who may be watching this hearing on a live stream.
I welcome and acknowledge the presence of Minister Camm, the minister directly responsible for the child protection system.
I also welcome and acknowledge the presence of Mr Luke Twyford, principal Commissioner of the Queensland Family and Child Commission. I will take appearances.
MS R SWEET KC: Commissioner, I appear with my learned juniors. Mr Nathan Boyd and Bianca Mendelson, as counsel assisting.
THE COMMISSIONER: Thank you, Ms Sweet.
MR P HASTIE KC: May it please the Commission, my name is Hastie, H‑A‑S‑T‑I‑E, initials PA, and I appear for the State of Queensland instructed by the Crown Solicitor.
THE COMMISSIONER: Thank you, Mr Hastie.
The terms of reference that you have just heard are broad and comprehensive. The breadth of the inquiry I have been charged to undertake manifests a resolve on the part of the Queensland Government that there should be a thorough and independent assessment of all matters associated with the child protection system in Queensland.
Notwithstanding the scope of this Inquiry, at its core, the Inquiry concerns the children and young people of Queensland, cared for under the child protection system, for whom the State is their notional parent.
The paramount aim of this Inquiry, as I see it, is to improve the lives of and outcomes for these children and young people. If that aim is achieved, and I shall do all that I can to see that it is, it will benefit not only those children but all of the community of Queensland.
If there is one matter about which we can all agree, it is the universal moral duty to care for and nurture and protect children and young people. This is a natural human instinct. However, when, for many different reason, a child or young person does not have a natural parent or family group to care for him or her, the State is called upon to step in and take over that most foundational role, with all that being a parent entails.
As the State is not a natural person, it must undertake the nuanced and demanding role of a parent by enlisting its departments and agencies to provide the range of needs and services that are essential to the care and nurture of a child or young person.
This is no simple matter as, needless to say, each child or young person is an individual, with unique needs and unique circumstances.
The children and young people in the child protection system come from a wide variety of backgrounds and cultures and from all parts of Queensland, from major towns and cities, from regional areas and remote communities. It is very clear that children and young people from Aboriginal and Torres Strait Islander communities, are grossly over‑represented in the child protection system.
The Commission will focus heavily upon the particular challenges faced by those communities and how the system might be improved to achieve better outcomes for Aboriginal and Torres Strait Islander children and young people.
The child protection system is vital to all parts of Queensland and hence the Commission will examine the system on a state‑wide basis, focusing on different needs and challenges that exist in different parts of the state.
The compelling need for the Inquiry becomes quite clear when one considers the high‑level figures to which I am about to refer.
The number of children in out‑of‑home care has increased from 7,999 in 2011/12 to 10,092 in 2023/24. Over the same time period, the number of First Nations children in out‑of‑home care has increased from 3,041 to 4,961.
The number of children in residential care has increased from 653 in 2011/12 to 1,994 in 2023/24. Over the same time period, the number of First Nations children in residential care has increased from 240 to 904.
The number of children in foster care has decreased from 4,579 in 2011/12 to 3,870 in 2023/24. Over the same period, the number of First Nations children in foster care has increased from 1,760 to 1,943.
The number of children in kinship care has increased from 2,767 in 2011/12 to 4,228 in 2023/24. Over the same time period, the number of First Nations children in kinship care has increased from 1,042 to 2,114.
The daily average number of children aged under 17 in youth detention has increased from 164 in 2011/12 to 292.1 in 2023/24. Over that same time period, the daily average number of First Nations children in youth detention has increased from 108 to 209.8.
The Carmody report records that as of 30 June 2012, 72 per cent of children in the youth justice system were known to the child protection system.
The Australian Institute of Health and Welfare reported that in 2022/23, 72.9 per cent of children under youth justice supervision had interacted with the child protection system in the 10 years prior.
The Carmody report also records that in 2011/12, 194 children subject to child protection order for more than 12 months had been under supervised youth justice order at some point during the same year.
As of 30 March 2024, there were 219 children subject to both a child protection order and a supervised youth justice order.
The Department of Families, Seniors, Disability Services and Child Safety reports that as of 30 June 2024, 3.1 per cent of children under child safety orders are also under supervised justice orders. That, in numerical terms, is 218 children out of a total of 7,026.
The proportion of children in residential care as a proportion of out‑of‑home care has increased from 8 per cent in 2011/12 to 20 per cent in 2023/24.
The proportion of children in foster care as a proportion of out‑of‑home care has decreased from 57 per cent in 2011/12 to 38 per cent in 2023/24.
The proportion of children in kinship care as a proportion of out‑of‑home care has increased from 34 per cent in 2011 to 42 per cent in 2023/24.
In relation to expenditure on the system, the annual budget for child safety services has increased from $735.45 million in 2011/12 to $2.14 billion in 2023/24.
Actual spending on child safety services has increased from $753 million in 2011/12 to $2.36 billion in 2023/24.
Actual spending on out‑of‑home care, which encompasses residential care, foster care and kinship care, has increased from $396.1 million in 2011/12 to $1.67 billion in 2023/24.
Actual spending on intensive family support and family support services has increased from $90.14 million in 2011/12 to $236.68 million in 2023/24.
I would like to say a little about the work of the Commission thus far and the plans for the future course of the Commission.
Starting with the work to date, the Commission formally commenced on 1 July. Thanks largely to the excellent establishment work of the executive director, Ms Jess Wellard, and senior counsel assisting me, Ms Robyn Sweet, in the preceding three to four weeks, the Commission was in a position to commence substantive work on the first day.
As of today the Commission has been able to assemble a nearly full complement of staff to help undertake the numerous and varied tasks that are essential to undertake in this Inquiry.
The Commission's website has been up and running since the first day and will be continuously populated with relevant material and information as the Inquiry progresses.
My work has commenced with many meetings over the last several weeks with key government departments and agencies and with non‑government interest groups and associations directly concerned with child safety.
It is an unavoidable incident of the State as the notional parent that many government departments are involved and each must play their role if the child safety system is to deliver optimal outcomes for children and young people.
The non‑government sector is also critically important. I have met with the peak association representing foster carers, with the peak body representing Aboriginal and Torres Strait Islander people, and with frontline support workers in Townsville who care for children and young people on a day‑to‑day basis at various non‑family residential care homes.
I have also met with the peak body representing third‑party providers of residential care homes.That organisation is directly involved in the child protection system in a number of capacities, both as a representative of third‑party providers and as an advisory body to the Department of Child Safety and other government agencies. It has undertaken substantial research programs in relation to various aspects of child safety, which I expect to examine in the course of the coming months.
I also expect that that organisation will be called to give evidence at public hearings, the first of which will commence in Cairns in late August or early September.
Within the Venn diagram of intersecting government departments, I have also met with the Youth Justice Department and visited the youth detention centre in Townsville I have met with the Queensland Commissioner of Police and senior officers directly involved in child protection and with the Director‑General of Queensland Health and senior staff involved in child protection. I anticipate there will be many further engagements with these and other government agencies and non‑government bodies.
Last, but by no means least, yesterday I attended a workshop, helpfully organised by the Queensland Family and Child Commission, with approximately a dozen young people with direct experience of the child protection system. I am pleased to note that one of those young people is present today.
Whenever possible, the Commission is keen to engage with and listen carefully to the unmediated voices of young people from within the system and to learn of their experiences.
Yesterday's meeting with these young people fortified in my mind the need to listen closely to their experiences, as they are able to give direct evidence about how the system works in practice from their unique point of view. They are, after all, the object of the system.
I heard from them about some experiences that were both surprising and, in some instances, troubling.
One of the many benefits of listening to these young people yesterday is that they informed me of certain matters about which I am now able to ask questions. Some of those questions had not previously occurred to me.
I propose to continue a dialogue with these young people and as many others as I can to ensure that I am informed of the right questions to ask from their perspective and so that their unique perspective is given real and genuine consideration in the crafting of any reforms that may ultimately be recommended.
I commenced substantive engagements with the Child Safety Department in Townsville last week. There I met with department officers who are responsible for all levels of the child protection continuum, from triaging calls about children at risk, to the first responders and to those who are involved in the assessment of appropriate care and accommodation arrangements, as well, as I have said, with frontline support workers.
I also met in Townsville with an Aboriginal Elder involved in the youth justice system and commenced learning about particular concerns and challenges faced by Aboriginal and Torres Strait Islander peoples in regional and remote communities.
In addition to the range of consultations to which I have referred, the Commission's staff have been busy in relation to information gathering at this early stage and in preparing tools for document management and analysis of what I expect to be a flood of material in the coming weeks.
The Commission has sent numerous notices to produce to government departments and agencies. Indeed, the skies over government offices have been blackened by a flock of notices in recent days. I am pleased to acknowledge that yesterday, the Department of Child Safety responded to the first round of notices and did so on time.
It is critical to the Inquiry that the Commission gather in and examine records that may shed light on the reasons for the significant increase in demand for and the exponential cost increase of child protection services in Queensland.
In due course, the Commission will examine procurement practices and market factors that may have a bearing on the very significant cost increases associated with child protection services since the last inquiry into the system under the Carmody Inquiry.
In that connection, the Commission will shortly direct notices to produce documents to third‑party service providers to assist in understanding how charges for services are arrived at.
The Commission will also look at various funding models and their impact on the overall cost increases.
The Commission will interrogate whether these charges are justifiable and consider whether various funding models used by the Department of Child Safety are appropriately balanced and reasonable, having regard to the practical exigencies overall, as well as particular market or other constraints that affect particular regional or remote areas.
I would like to now turn to saying a little about the future plans of the Commission.
As I have said, the Commission commenced substantive engagements in Townsville. That starting point presaged the Commission's plans for the first substantive public hearings to be held in Cairns, as I have mentioned.
The Commission commenced in Townsville for several reasons.
First, Townsville is a major regional area, where there is a high level of demand for child protection services.
Second, Townsville is an area which manifests some of the more difficult challenges in providing child protection services, including: the remoteness of some of its surrounding communities; the lack of certain services in some of the surrounding communities; labour shortages in certain areas; and supply‑side constraints.
It is already abundantly clear that any reform or improvement to the child protection system cannot be approached on the basis of a one‑size‑fits‑all solution across Queensland.
The third reason for commencing in Townsville is that I wish to make it clear from the outset that the Commission will undertake a whole‑of‑Queensland approach as well as a whole‑of‑government approach.
Wherever possible, public hearings will be targeted at hearing from groups, associations and individuals with direct involvement in or experience of the child protection system.
In regional and remote areas, the Commission will be particularly interested in hearing about local factors that have a bearing on the way the child protection system operates in practice, as well as what may be improved, including potentially alternative forms of care for children and young people in child protection that are not presently available.
Senior counsel assisting me will have more to say about the planning for forthcoming hearings and some of the themes which will be explored at those hearings.
Public hearings are undoubtedly an important element in the process to be employed by the Commission, but are by no means the only means.
Public hearings are important for a number of reasons. They enable the community to participate in and scrutinise a good deal of the work of the Commission.
I hope the public hearings will encourage interest in the work of the Commission and encourage interested parties to make submissions and potentially give evidence in open forums.
I should make it clear that the public hearings will not take the form of "town hall" meetings, as that style of public engagement lacks the rigour the Commission aims to bring to the analysis of matters about which it is charged to investigate.
Rather, the process will involve counsel assisting, together with the Commission staff, identifying witnesses who can give evidence about topics and themes which bear upon the terms of reference.
One of the ways this will be achieved is through anterior workshops with key interested groups. One aim of such workshops is to identify witnesses and case studies in relation to particular topics or issues.
The Commission does not intend to undertake an academic or theoretical study, though close attention will be given to good‑quality literature and empirical studies that address matters within the terms of reference.
The Commission will give priority to gathering evidence on the ground and from the ground up, so that the present design and functioning of the child protection system may be scrutinised against the background of what actually occurs, rather than from any theoretical or ideological perspective.
This approach will ensure that any suggested reforms may be "stress tested" in the course of the Inquiry against the measure of what is real and practical, having regard to all of the exigencies that bear upon the State as the notional parent of many children and young people dispersed throughout Queensland.
The Commission has already commenced the process of inviting submissions in relation to certain topics. In due course, other topics will be added to the list on a progressive basis.
The Commission will review all submissions carefully, including for the purpose of identifying witnesses who might give evidence in public hearings.
The importance of real and genuine consultation with Aboriginal and Torres Strait Islander communities in relation to the child protection system cannot be overstated.
The fact that children and young people from these communities are grossly over‑represented in the system is alone a sufficient basis for close and specific attention to these communities. But it is by no means sufficient to regard the numbers of Aboriginal and Torres Strait Islander children and young people in detention as furnishing some self‑evident conclusions about why these communities are over‑represented, much less any conclusions about what should be done to abate these statistics. Any such analysis would invert cause with effect and conflate those issues.
The Commission proposes to meet with as many groups representing Aboriginal and Torres Strait Islander peoples as possible. The Commission will listen to their experiences and to their views about how to improve outcomes for their children and young people.
To that end, I intend to take advice from these expert groups about how to best engage with their regional and remote communities and, with the benefit of that advice and assistance, shall meet directly with Aboriginal and Torres Strait Islander peoples, including, whenever possible, children and young people.
The gross overrepresentation of young Aboriginal and Torres Strait Islander people in the youth justice system also cannot be ignored in the context of the child safety setting.
The terms of reference require that I examine any connection between the experiences of these young people in child protection and their over‑representation in the youth justice system.
Again, the Commission will not draw any simplistic conclusions about cause and effect when it comes to examining this issue. However, the question of whether the child protection system is well designed and operated to avoid child protection services becoming a feeder into the youth justice system must be considered.
I also propose to consider other potential hybrid alternatives to youth detention before and/or after the young offender may have been sentenced to youth detention in one form or another.
This issue will be explored over the coming months with the benefit of input from all relevant participants in the system.
I want to say something about some emerging themes that have emerged already.
Even in the short time that the Commission has been under way, some themes have emerged from early discussions. It would not be wise to jump the gun by saying too much about those themes at this stage, however, I would like to mention one theme that has come up in discussions with young people who have been in the system and also with foster carers and support workers at residential care homes.
The theme concerns the question of whether the carer's duty to children and young people is matched by the authority of the carer necessary to effectively discharge that duty. Put slightly differently, the question is whether there is a disconnection between the carer's duty of care on the one hand and his or her authority necessary to fulfil and discharge that duty.
This issue potentially arises whenever a person is given responsibility for the direct day‑to‑day care of a child or young person, acting, effectively, as that young person's parent.
It is a theme or issue which is relevant to all three forms of care currently provided ‑ that is, foster care, kinship care and non‑family‑based residential care.
The issue also has ramifications for the safety of frontline carers and for the protection of the community. It is related also to the mechanisms and procedures available to frontline carers to raise behavioural or other issues and to make complaints without the fear of adverse consequences for themselves. The latter issue has been in the press in recent weeks and the Commission has accelerated seeking submissions in relation to that subject.
While visiting a residential care home in Townsville, I was told by one of the frontline support workers of an incident that puts this issue into some focus. The support worker was caring for a young girl with serious suicidal tendencies.
To cut a harrowing story short, the young girl jumped into oncoming traffic, or attempted to. The support worker grabbed the girl by the back of her hoodie and pulled her backwards to prevent her from being run over by an oncoming vehicle. This, of course, happened in a split second, and was a reflex action on the part of the support worker. The young girl fell backwards onto her bottom involving some bruising, but her life was saved.
This incident was, of course, reported. But there then followed an investigation, spanning some three months, into the action taken by the support worker.
There is much that may be drawn from this incident, including the observation that frontline carers often work under extremely demanding and stressful conditions, especially when the child or young person is suffering from a mental illness or other behavioural difficulties.
One may also ask whether carers are sufficiently supported when adverse incidents occur through no fault of their own, and also whether there is clarity about what carers may do to protect those in their care from harming themselves or others or harming the carers themselves.
These issues also overlap with the ability of carers to report and raise complaints about matters which impact their safety and the safety of other children and young people in the facility.
The relationship between the notional parent, in the form of a carer, and the child or young person is obviously a nuanced one. There is a balance between the young person's freedom to express themselves and to grow into adulthood and the authority of the carer to exercise the kinds of normal constraints any parent might exercise to impose boundaries in relation to the young person's freedom and behaviour.
These are qualitatively nuanced matters, but must be capable of clear understanding by carers and young people if the relationship is to be a healthy and constructive one.
There must be clarity about those matters if we are to expect carers, whether foster carers, kinship carers or support workers, to discharge their duty to care for young people in their capacity as carers for and on behalf of the state.
During my meeting with the young people yesterday I have already mentioned, we discussed this nuanced issue. My impression was that they understood and accepted that frontline carers must have the authority and controls appropriate to discharge their duty, but they also said, in essence, that there was a need for less risk‑averse brittleness in the exertion of control and more negotiation about boundaries as a young person grows into adolescence and matures. This is the kind of negotiation I am sure all parents of adolescent children are familiar with.
One of the challenges of this Inquiry is to translate the nuanced elements of the relationship between a child and a parent in the context of the State as the notional parent.
How does the State conduct the negotiations that must inevitably arise on a daily basis between a carer and a young person in the child protection system, as the child grows into a young adult and wants, naturally, to express their individuality?
How can carers within the state system be empowered with a range of discretions, consciously or unconsciously exercised by parents on a daily basis, so that they may truly stand in the shoes of a reasonable and loving parent while at the same time not be at risk of adverse judgment whenever some latitude turns out, with the benefit of hindsight, to have been a mistake?
These are but some of the nuanced questions that the Commission will grapple with from the perspective of carers and from the perspective of the cared for.
If I may circle back to the incident concerning the support worker who prevented a young woman from committing suicide, needless to say, it reveals just how difficult the job of being a carer is, especially when one considers the boundless myriad of daily events that they are required to cope with.
This Commission will examine the terms of reference with a clear appreciation, from the outset, that systemic solutions must consider the ineluctable individuality of the task of caring for children and young people in the child protection system.
I hope that what I have said has provided some picture of the scope of this Inquiry and the approach the Commission proposes to take to it.
This hearing is the beginning of a process of public engagement, and again, I encourage all groups and individuals with an interest in this vitally important subject to come forward and make submissions to the Commission, to help ensure, as far as possible, that no relevant evidence or informed opinion is overlooked.
Before inviting senior counsel assisting me to address the Commission, I should mention that I have noted the reports in this morning's press concerning some 780 children who have been reported to have gone missing from State care. This is plainly a matter of serious concern. The circumstances surrounding that situation will be investigated by the Commission.
Once again, I thank everyone who has attended today's hearing, in person or remotely, for their attendance and for their interest in the work of the Commission.
I will now ask senior counsel assisting me, Ms Robyn Sweet KC, to address the Commission.
MS SWEET: Thank you, Commissioner.
The task of this Inquiry is vital. It is urgent and it is wide‑ranging. It requires you, Commissioner, to conduct a full and careful inquiry in an open and independent manner of the matters identified in the terms of reference and any other matter you deem relevant, and the making of recommendations which you consider are feasible, appropriate, and promote the protection of children in Queensland into the future.
I want to talk briefly about the background to the calling of this Inquiry.
The last Commission of Inquiry into Child Safety in Queensland was undertaken between 2012 and 2013 and is known as the "Carmody Inquiry".
Referred to as a "root and branch" inquiry into the entire child protection system, the Carmody Inquiry was asked to deliver a roadmap that would take Queensland, within a decade, to the best possible system for supporting families and protecting children that the state could afford. The roadmap that eventuated contained 121 recommendations directed to this end.
More than a decade later, the reported figures show, Commissioner, as you have mentioned, exponential growth in the demand for child safety services, the number of children in out‑of‑home care and the cost of the system.
The Queensland Family and Child Commission recently reported that from 2018 to 2023 there had been an 85 per cent growth in children and young people in residential care.
This is a phenomenon unique to Queensland with no other Australian jurisdiction experiencing such an explosion in children in residential care.
The data shows that Queensland had 40 per cent of Australia's residential care placements in that period, despite only having 21 per cent of the nation's children in care.
The residential care system is designed for children between 12 and 17 years old, yet one in three children in residential care in Queensland are under 12. There are scores of children in residential care under the age of 5.
This means that children under school age are living in a non‑family‑based care environment, not with their parents, not with kin and not with foster care. There are even reports of infants being placed into residential care, a system designed for teenagers and designed to be staffed by youth workers, not early childhood trained professionals. The adequacy of this state of affairs requires serious interrogation and review for the sake of all involved.
We have seen in recent media reports allegations of threats and physical violence by young persons within the residential care homes, allegations of a failed complaints system to support workers, as well as allegations of young people in residential care being targeted, procured and recruited for the purpose of sexual exploitation. These allegations are matters of considerable concern, to which the Inquiry will turn its attention as it progresses with its work.
As the number of children in the child safety system increases, so, too, does the fiscal imprint of the child safety system. The cost of residential care alone has increased from $200 million to a forecast $1.12 billion a year over a 10‑year period.
Based on child safety figures, the average cost of a child in residential care as at December last year was $1,360 a day. At that time, there were 2,093 children living in residential care. This means that the average cost to the taxpayer per day for children in residential care is approximately $2.8 million.
The increased number of children in residential care is clearly having a tangible impact on the Queensland budget.
These statistics are useful in highlighting a particular issue within the child safety system. There are many more I could recite which demonstrate that the system is under stress.
It is also important to bear in mind that behind each statistic are the stories and experiences of children, young people, carers and others involved within that system.
The Inquiry team will be looking beyond the statistics to hear the experiences of people who have interacted with the child protection system so we can best assist you, Commissioner, in conducting this Inquiry and making appropriate, practical, evidence‑based recommendations on the actual experiences of those in and most affected by the operation of the child safety system.
The government stated in a media release that its decision to call this Inquiry was made "following the uncovering of long‑term systemic failures", and that this Inquiry was "a critical step in the reform process of the child safety system".
It is the role of this Inquiry to review and investigate any systemic issues within Queensland's child safety system, make findings on any failures of the system and their impact, and to make feasible and appropriate recommendations for the protection of vulnerable children and young people in care, their families, their carers and the wider community.
The Inquiry is due to report on 30 November 2026.
I want to now say something about the work of the Commission to date, but before I do that, I want to acknowledge that there is a vast body of work that exists in respect of child protection and child safety issues that has been undertaken by prior federal royal commissions, state commissions of inquiry across Australia, as well as parliamentary committees, oversight bodies and peak bodies. Some of this work is ongoing. We acknowledge that work and are cognisant that it may be of assistance to the Inquiry in discharging its remit.
Significant work has been done so far by you, Commissioner, by the counsel assisting team, and the staff of the secretariat, although, of course, the bulk, the vast bulk, of our work is in front of us.
Between the issuing of the Letters Patent on 16 May 2025 and the formal commencement of the Inquiry on 1 July, premises were identified and set up to house the secretariat; the counsel assisting team was established; recruitment of the Inquiry's secretariat staff commenced; a strong, agile and multidisciplinary team has now been assembled, ably led by executive director Jess Wellard, with staff employed in investigative, policy, operational and legal streams.
I thank each member of our team for joining the Inquiry and the energy, dedication and expertise they bring to it.
With the assistance of the Department of Justice, the Inquiry's website, childsafetyinquiry.qld.gov.au was established and went live on 1 July 2025. Practice guidelines were drafted, which have been published on the website on 1 July, and I will return to some of those later. Relevant agencies and important stakeholders were identified and the terms of reference were scrutinised with a view to mapping out the Inquiry's critical path, including its schedule of public hearings.
Since the formal commencement of the Inquiry, Commissioner, on day one, one of your first acts was to call for submissions into a priority issue for the Inquiry, to which you have alluded, namely, the call was for submissions into the adequacy of the existing complaints system, procedures and incident reporting guidelines for those wishing to raise serious safety concerns about children under the care of the State. This includes safety and other concerns in relation to residential care facilities, foster and kinship care placements, and services delivered by funded service providers.
Submissions will be accepted on that particular topic until 1 August 2025. Submissions can be provided via the Inquiry's website, by email or by post.
Submissions on other topics will be called for from time to time. Those calls will be published on the website.
Submissions can be sent to the Inquiry using the online form which appears on the Inquiry's website.
To date, the Inquiry has received 61 submissions, each of which has undergone an initial individual review by a member of the Inquiry's team.
The submission have been received from various child safety regions across the state, from Central Queensland, from Darling Downs, from Far North Queensland, from North West Queensland, and from South East Queensland.
More than a third of these submissions have been from parents with children currently under the care of the State. One fifth have been from current and former foster carers.
We have also received submissions from other family members, kinship carers, former child safety staff, adults who were children within the safety system, academics and general members of the community.
I thank everyone who has provided submissions to the Inquiry thus far. We hear you, we are listening, your contribution helps to direct and sharpen our focus and inform our work. Thank you for taking the time and effort to share your experiences and perspectives with us. It is invaluable. I urge anyone with a concern, feedback or information of potential relevance regarding the child safety system in Queensland to make a submission in writing to the Inquiry and have your voice heard.
I now want to talk for a moment about the issuing of notices and the production of documents to the Inquiry.
Commissioner, as you are aware, you have extensive compulsory powers that can be used as part of the Inquiry's information‑gathering process.
You earlier referred, Commissioner, to the issuing of notices to produce to various agencies and entities, compelling them to provide documents and information to the Inquiry. Notices will continue to be issued on a regular basis.
The Inquiry is relying on the recipients of these notices, be they agencies or individuals or entities, for their cooperation and assistance in the timely and transparent provision of information.
The information, documents and data sought is critical for the Inquiry to have the necessary basis to draw conclusions about the matters set out in the terms of reference and make appropriate recommendations as to any reforms to the child safety system, and may I direct people's attention to the website where there is a practice guideline that deals with the production of documents to the Inquiry.
The Inquiry expects to receive many hundreds of thousands of pages of documentation as a result of its issuing of notices to produce.
I now want to say something about consultation and public engagement by the Inquiry.
You have referred, Commissioner, to various meetings with agencies, peak bodies and other interested parties here in Brisbane.
You also mentioned your first public engagement visit to the important regional centre of Townsville. In that time, you visited child safety service centres, residential care homes, both licensed and unlicensed, the Cleveland Youth Detention Centre, and commenced your engagement with the Aboriginal and Torres Strait Islander community.
This visit gave you the opportunity to engage directly with many frontline workers and listen to their perspectives on the current child safety system, its strengths and weaknesses and what they saw as critical reforms required.
You also undertook print, radio and television media commitments whilst in Townsville to inform the public about the Inquiry and its work, to encourage community interest and participation in the Inquiry, and to underline that this is an Inquiry for the whole of Queensland.
Allow me to ensure those in the Townsville region that this was not a public hearing. No‑one has missed their chance to provide the Inquiry with information, which can be done in a variety of ways, including through making a submission via the website. This was a visit to commence regional public engagement and consultation in a place where there was a strong demand, is a strong demand, for child safety services.
Visits such as these, which we will continue to do throughout the Inquiry, assist to identify and clarify areas of focus for the Inquiry, identify topics for public hearings, identify classes of witnesses to provide public evidence, and identify potential witnesses.
Various themes emerged from this visit to Townsville, one of which, Commissioner, you have touched upon in your opening remarks, namely, whether there is a disconnect between the duty imposed upon carers and the authority needed to acquit this foundational role in the best interests of that child and young person and taking into account the need to steward that person into adulthood as a functioning and engaged member of society.
Other emerging themes were as follows: the challenges of delivery and the cost of child care safety services in regional and remote locations and the extent to which scarcity of supply, labour shortages or practical issues such as the distance in play, particularly in regional areas, and what alternative models of care might be available to meet the needs of those persons in remote areas effectively and efficiently.
Another theme was the adequacy of the training of residential care staff who are caring for children under five.
One theme that emerged was the decline in the number of foster carers over time and the drivers for this reduction and innovative ways to arrest and reverse this decline.
Another theme was the hurdles faced by potential kinship carers in obtaining blue card status.
The theme of the caution system within the Murri Court and the role of young, reformed offenders in providing guidance, hope and optimism to young Aboriginal and Torres Strait Islander youths to complement the established role of Aboriginal and Torres Strait Islander elders was discussed.
The potential development of new alternative options for care of young people in between residential care and youth detention was raised, as was what measures are needed to reduce the rates of recidivism in young persons who have been the subject of dual orders upon their release from detention.
I wish to stress that listening to the voices of children and young persons firsthand is critical, is a critical component of the work of this Inquiry. Those experiences will be critical to informing the work of the Inquiry and the Inquiry has a youth engagement plan, which you commenced implementing yesterday, Commissioner, with your focus group facilitated by the QFCC.
I want to say something now about the scheduling of public hearings.
One of the ways, but by no means the only way, that the Inquiry will undertake its work is through the conduct of a series of multi‑day public hearings throughout its term, in various locations throughout the state. The timing and scope of these hearings will be released on the website to the public in advance.
In respect of the process for leave to appear, that process, the process for seeking leave to appear at a round of public hearings, is contained in practice guideline number 3, which is available to the public on the Inquiry's website. Those applications should be made via the form that is now available on the website. Generally speaking, applications for leave will be determined by you, Commissioner, on the papers.
Generally, an applicant will be granted leave to appear if they are the subject of a particular issue the Inquiry will investigate at that public hearing; if they may be the subject of an adverse finding; or will be able to materially assist the Inquiry at that public hearing.
It is anticipated that, in most cases, any grant of leave will be the subject of conditions. Typically, a grant of leave will be confined to the particular public hearing to which the applicant has an interest, with limitations on the topics or issues upon which they may call evidence and/or cross‑examine witnesses.
A person or organisation who wishes to appear at a round of public hearings should do so at the earliest opportunity and at least seven days prior to the commencement of the hearing via the website form, and reference should be made in that form to the relevant parts of the terms of reference in that person's submission.
As you have mentioned, Commissioner, the first round of public hearings will commence in late August or early September in Cairns. A document indicating the scope of that public hearing will be published on the Inquiry's website prior to its commencement.
As I have said, public hearings are only one way, albeit a very important way, in which the Inquiry will carry out its work. It is also at your discretion, Commissioner, to hear evidence by way of private hearing as you consider appropriate, and of course, much of the Inquiry's work will involve the close scrutiny and analysis of transcripts, submissions and other documents produced to the Inquiry, which the public will not see, but which will be undertaken assiduously at the premises of the secretariat. The Inquiry will also be supported by a targeted research and policy program.
I now want to speak briefly about the issue of confidentiality.
The Inquiry is conscious that the terms of reference will necessarily require investigating sensitive topics and issues that people may be reluctant to discuss in a public setting.
It is expected that some people who have information that is relevant to the work of the Inquiry may hold legitimate concerns about sharing that information with the Inquiry if their identity cannot be kept anonymous. While there will be many genuine reasons to have concerns about anonymity, some of those reasons may include: sensitive and personal subject matter of the information; nervousness or anxiety about giving evidence in public; fear of reprisals at a workplace or in the community; fears of harming future career prospects; and concerns about the confidentiality of the information they possess.
The Inquiry is sensitive to these concerns and recognises the personal impact that giving evidence or being publicly identified may have.
In recognition of this, the Inquiry has procedures in place to protect the anonymity of people who do not wish to be identified. The details of these procedures will be published on the Inquiry's website in due course. However, I say today that some of the measures available to protect a person's privacy will include: giving evidence in a closed hearing, from which the public is excluded; providing evidence by way of a witness statement, which is not then the subject of a public hearing; providing information to identify lines of inquiry without providing a formal statement; providing documents on a confidential basis, such that they will not be released to anybody outside the Inquiry; non‑publication orders prohibiting the publication of any evidence or documents provided to the Inquiry; the Inquiry may also elect not to publish specific information or material on its website or in its reports and may need to redact submissions, transcripts, witness statements or other documents prior to publication if necessary.
The Inquiry is cognisant that the issues being investigated may be very personal to those wishing to give evidence and that witnesses will hold genuine concerns about the consequences of them giving evidence to the Inquiry.
I encourage any person who has these concerns to review the confidentiality procedures which will be published on the Inquiry website and to contact the Inquiry to discuss what protections may be available to them. The Inquiry team will work with you to ensure you feel adequately supported to assist the work of the Inquiry.
I now want to speak briefly about statutory protections of witnesses in the Inquiry.
It is possible that some people may be reluctant to provide information to the Inquiry because of concerns they may have regarding confidentiality obligations owed under a contract or in the course of their employment or for fear of reprisals.
The Commission has the power, under section 5 of the Commissions of Inquiry Act, to require persons to provide information or documents to the Inquiry or to summons a person to appear.
Information and documents given to the Inquiry in answer to notices to produce or a summons under section 5 do not amount to a breach of confidentiality owed under a contract or in the course of the potential witness's current or previous employment, including public servants.Further, section 14B of that Act grants every witness before the Inquiry the same protections as a witness of the Supreme Court.
With respect to reprisal actions, it is an offence under section 23 of the Act for an employer to dismiss an employee from employment or take action that prejudices an employee because the employee appeared as a witness before the Inquiry or gave evidence to the Inquiry.
Anyone with concerns as to the adverse impacts for them if they gave evidence to the Inquiry should contact the Inquiry and any information received will be treated in the strictest confidence.
The Inquiry would be greatly concerned if an employer or organisation sought to discourage someone with relevant information from providing it to the Inquiry or otherwise took action against a person because of their participation in the Inquiry.
If the Inquiry became aware of such action, including any such action against a department employee for providing information, the Inquiry may consider invoking its coercive powers to scrutinise that action and the reasons for it.
I want to say something briefly about disclosure of information.
Due to the investigative aspect of the Inquiry's work, it is essential that the Inquiry itself decides when and to what extent it discloses information that it has collected, as well as when and to what extent it discloses the particular courses of action that it proposes to take. To disclose such information prematurely has the potential to prejudice the effective performance of the Inquiry's work.
May I just make a few remarks in conclusion.
A fresh and independent look at the child safety system is warranted. The apparent change in the age, number and needs of children in care, the reduction in foster carers and the exponentially expanding cost of the system demand investigation in order to determine what solutions are fit for purpose for today's society and the current social and economic challenges that our children, families, carers and the community face.
The Inquiry provides a significant opportunity to design practical, evidence‑based, innovative reforms, to do a number of things: to help create stable, positive and uplifting generational change for the state's most vulnerable children and young people; to support, protect and empower carers in family‑based and non‑family‑based care in the performance of their important roles; to provide new or enhanced models of care for managing escalating risks and behaviour to keep children, carers and the wider community safer; and to reduce the fiscal burden on the taxpayer of the child safety system.
This morning I have sought to outline the processes by which it is intended the Inquiry is to run. Further details as to the Inquiry's work and the direction it will take will be posted on the Inquiry's website.
I encourage all interested parties to explore the website, childsafetyinquiry.qld.gov.au. The transcript of this hearing and all further public hearings will be published and available for review on the Inquiry's website.
Commissioner, the counsel assisting team relish the challenge of this Inquiry and are looking forward to supporting you in the critical work that you will undertake over the next year and a half which has the potential to positively influence the lives of countless Queensland children, their families and the broader community.
THE COMMISSIONER: Thank you, Ms Sweet. The Commission will adjourn.
