FAQ
About the inquiry
1. What is the inquiry about?
The inquiry examined the experiences of 19 of Western Australia’s most vulnerable children, all of whom had been placed in the Kath French Secure Care Centre three or more times between 2020 and 2025. It followed their journey through out-of-home care to understand their experiences, the decisions made about their care, and how the child protection system responded to their needs.
The inquiry identified opportunities for systemic reform, with 50 findings and 56 recommendations aimed at improving outcomes for children and young people in care.
2. What is meant by out-of-home care?
Out-of-home care (OOHC) refers to care arrangements for children who cannot safely live with their parents or usual caregivers. Depending on their circumstances, children may live with relatives or kin, foster carers, or in residential care.
Each child’s circumstances and needs are different. Care arrangements should prioritise safety, stability, wellbeing, family relationships and, for Aboriginal children, connection to culture, community and Country.
3. Why has the Commissioner undertaken this inquiry?
Under section 19 of the Commissioner for Children and Young People Act 2006 (WA), the Commissioner can conduct inquiries into any law, practice, procedure or service affecting the wellbeing of children.
This inquiry was focused on alignment of OOHC practices with guiding legislation, policies, procedures and frameworks. The inquiry sought to understand whether the child protection system is adequately protecting and supporting vulnerable children with complex needs, and what needs to change to ensure children receive the right care, at the right time, for as long as they need it.
It focuses on the system’s responsibilities, rather than placing the burden on children to navigate fragmented services or overcome gaps in care themselves.
Every child has the right to be safe, to be cared for, to have their needs met and to be heard in decisions that affect their lives.
4. Why does the inquiry focus on 19 children?
This Inquiry focused on those children and young people in OOHC who were determined as being ‘high risk’ and having ‘complex needs’, which is defined as children and young people admitted to Therapeutic Secure Care three or more times over a five-year period.
The Department of Communities identified 19 children and young people who met the selection criteria.
The provided sample was used to assess the ability of the Department of Communities to meet its statutory obligations for a cohort acknowledged as the most vulnerable, which more broadly reflects the ability of the out-of-home care system to achieve core functions for those most in need of support.
The experiences of these 19 children provide an opportunity to examine the child protection system in depth, including how decisions and interventions affect children over time.
Following individual journeys allows the inquiry to consider the cumulative impact of placement changes, service responses and gaps in support, rather than looking at individual incidents or decisions in isolation.
The findings are intended to identify broader systemic issues and improvements that can benefit children across Western Australia.
5. Why were children who have experienced Secure Care selected?
Secure Care is a short-term, intensive care placement for children and young people in care who pose an immediate and substantial risk to themselves or to others, where there is no other suitable way to manage that risk and support the child or young person in receiving the care needed. The report considers these experiences as part of their broader journeys through the care system.
The report specifies the relevant settings and explains how the term is used, so readers can clearly distinguish secure care from residential care, youth detention and other care arrangements.
These children have experienced particularly complex and challenging circumstances and have had contact with multiple parts of the care system. Examining their experiences provides insight into how the system responds when children have significant and ongoing support needs, and whether the care provided is meeting those needs.
The inquiry also considers how the system might intervene earlier and provide more effective, coordinated support to prevent children’s circumstances from escalating.
What the inquiry examined
6. What aspects of the child protection system were examined?
The inquiry follows the children’s experiences across their OOHC placements and considers how the system has responded to their needs over time.
This includes examining the decisions, services, supports and transitions that shaped their experiences, and identifying where responses were effective, where gaps emerged, and where improvements are needed.
The report should be consulted for the precise scope of the inquiry and the specific issues examined.
7. Why is it important to examine children’s journeys over time?
A child’s experience cannot always be understood by looking at a single placement or decision.
Repeated placement changes, disruptions to important relationships, delays in accessing services and gaps in planning can have cumulative effects on a child’s safety and wellbeing.
Following children’s journeys helps identify how decisions made by different services interact, and whether the overall system is providing continuity of care and responding to children’s changing needs.
8. Were the children’s experiences central to the inquiry?
The inquiry places the experiences of the 19 children at the centre of its examination of the system.
Understanding children’s experiences is essential to determining whether policies, practices and services are working as intended. Children’s perspectives can also reveal problems that may not be apparent through administrative records or formal processes alone.
The report explains how children’s views and experiences were gathered and incorporated, while protecting their privacy and dignity.
9. Does the inquiry focus on individual workers or families?
The inquiry is concerned with understanding systemic issues and identifying practical improvements to the child protection system. Its purpose is to examine how systems, policies, decisions, resources and services operate together, and what government can do to improve outcomes for children.
Where individual decisions are relevant, they should be understood within the context of the evidence and the broader system in which they occurred.
Findings and recommendations
10. What has the inquiry found?
The inquiry makes 50 findings arising from its examination of the children’s journeys through OOHC. Together, these findings identify issues requiring attention and opportunities to strengthen the way government and services respond to vulnerable children.
Key findings include:
- Inability of the child protection system to uphold the best interests of children and young people in care, a core legislated obligation.
- Extensive, ongoing instability in out-of-home care placements.
- Minimal engagement with children and young people about their needs, wants, experiences and thoughts.
- Reactive and punitive responses to complex needs.
- Lacking multi-disciplinary collaboration and provision of holistic supports across the out-of-home care journey.
- Superficial consideration and inclusion of Aboriginal and Torres Strait Islander Child Placement Principles.
The final report provides the authoritative account of each finding and the evidence underpinning it.
11. How many recommendations has the Commissioner made?
The inquiry makes 56 recommendations directed at improving the child protection system and the experiences of children in care. The recommendations are intended to inform government action and support meaningful improvements to the safety, stability, wellbeing and long-term outcomes of vulnerable children.
Key recommendations include:
- Ensuring that children’s voices are heard and actively inform their care planning.
- Upgrading client management systems within the Department of Communities, inclusive of providing better case documentation and embedding an independent audit process.
- Developing shared systems across key government agencies that include universal referral forms and mechanisms for data collection to monitor outcomes for children in out of home care.
- Increasing the number of independent advocates for children and care.
- Designating the Kath French Secure Care Centre as a mental health facility to ensure necessary oversight and protection in relation to the rights, advocacy and support for children and young people with mental health conditions in care.
The final report sets out the complete recommendations and identifies the relevant agencies or decision-makers responsible for responding to them.
12. What are the recommendations intended to achieve?
The recommendations aim to identify practical ways government can improve the care and support provided to vulnerable children. They are intended to inform changes that strengthen the system’s ability to respond to children’s needs, improve coordination between services, address gaps in care and ensure children’s experiences inform decisions about their lives.
The specific objectives and proposed actions are detailed in the report.
13. Are the recommendations directed at one government department?
The inquiry examines children’s experiences across the care system. Improving those experiences may require action by multiple government agencies and service providers.
Where children’s needs span different services, coordinated responses are essential. The recommendations should be considered by the relevant agencies and government decision-makers, with clear responsibility for implementation. The final report identifies the recipients of individual recommendations.
14. Does the inquiry make recommendations about individual children’s cases?
The inquiry uses the experiences of the 19 children to examine the system and identify opportunities for improvement. Its recommendations are intended to address the issues identified through the inquiry and support better outcomes for children more broadly. Any case-specific actions should be described only where they fall within the inquiry’s scope and are supported by the report.
What happens next?
15. What does the Commissioner expect government to do in response?
The Commissioner expects the findings and recommendations to receive serious consideration and a clear response from government. A meaningful response should explain which recommendations government accepts, how accepted recommendations will be implemented, who is responsible, and how progress and outcomes will be measured. Children and young people need to see tangible improvements in their experiences of care, not simply commitments to future action.
16. How will the recommendations improve outcomes for children?
The intended benefit is a child protection system that better recognises and responds to children’s individual needs and provides appropriate support throughout their time in care.
The recommendations provide a basis for government to address identified gaps, strengthen accountability and improve the quality and continuity of care. The impact will depend on the actions taken in response and whether those actions lead to measurable improvements in children’s safety, wellbeing and experiences.
17. Will the Commissioner monitor the government’s response?
The Commissioner’s role includes advocating for children and young people and drawing attention to issues affecting their safety and wellbeing. Any formal monitoring, reporting or review arrangements associated with this inquiry should be set out in the report or subsequent public statements. The Commissioner will continue to advocate for children’s rights and for meaningful action to address systemic issues affecting vulnerable children.
Protecting children’s privacy
18. Will the children involved be identified?
Children’s privacy, safety and dignity must be protected throughout the inquiry and in the publication of its findings. The report and associated communications do not disclose identifying details. The focus is on understanding the system and improving outcomes, not exposing children’s personal histories to public scrutiny.
19. Why should the public care about the findings?
The way government responds to children who need protection is a measure of its responsibility to safeguard their rights and wellbeing. The experiences of these 19 children provide an opportunity to identify what is not working and what needs to change. The findings and recommendations are intended to support improvements that benefit vulnerable children across Western Australia. Every child deserves safe, stable and appropriate care, and a system that listens to them, recognises their needs and acts in their best interests.
Further information
20. Where can I read the report?
The full inquiry report, including its findings and recommendations, can be found on the Commissioner’s website.
A Young People’s Summary Report is also available online.