This report is the first from the Ombudsman’s investigation related to recommendation 5.2 of Public hearing 33 – Violence, abuse, neglect and deprivation of human rights: Kaleb and Jonathon (a case study). The hearing was conducted by the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability in 2023.
Kaleb and Jonathon (pseudonyms), two young men with profound disabilities, were found in their home by emergency services on 27 May 2020. The report on Public Hearing 33 stated that they were ‘locked in a room, naked and [with] no bedroom furnishings’. Their father and primary carer, Paul Barrett, was found deceased at the property.
The Royal Commission examined the experiences of Kaleb and Jonathon across 20 years to determine how and why they experienced violence, abuse, neglect and a deprivation of human rights in their childhood and early adolescence.
The Royal Commission recommended that the State of Queensland apologise for the omissions in preventing the harm they experienced. On 12 September 2023, this apology was delivered.
Why we investigated
On his own initiative (see section 18(1)(b) of the Ombudsman Act 2001), the Ombudsman commenced an investigation in response to recommendation 5.2 of Public Hearing 33, which stated:
The State of Queensland should conduct an independent review into the powers and responsibilities of all the departments and agencies that engaged with Kaleb, Jonathon and Paul Barrett to examine:
- the response to the violence, abuse, neglect and deprivation of Kaleb and Jonathon’s human rights
- what each department or agency could and/or should have done to prevent the violence, abuse, neglect and deprivation of human rights Kaleb and Jonathon experienced
- whether the current policies and practices are sufficient to prevent the nature and extent of the violence, abuse, neglect and deprivation of human rights occurring to children with disability.
In keeping with this recommendation, the focus of our investigation is on the relevant agencies’ current practices and procedures. These agencies include Education, the Department of Housing and Public Works, Queensland Health and the Department of Families, Seniors, Disability Services and Child Safety (Child Safety). We want to know whether they will adequately prevent the nature and extent of the violence, abuse, neglect and deprivation of human rights that Kaleb and Jonathon experienced from occurring in future to children with disability.
Our first report focuses on Education. The Ombudsman will report separately about the investigation’s findings in relation to the practices and procedures of other public sector agencies that engaged with Kaleb, Jonathon and Paul Barrett.
On 11 October 2023, the Ombudsman gave a notice under section 27(2) of the Ombudsman Act to the then Director-General of Education, informing him of the decision to conduct an investigation in accordance with section 18(1)(b) of the Ombudsman Act.
Scope of the investigation
We considered key periods during Kaleb and Jonathon’s schooling and used this information to:
- identify and assess current practices and procedures of Education that are relevant to ensuring children are safe and protected
- determine whether these practices and procedures are sufficient to prevent the harm that Kaleb and Jonathon experienced
- identify improvements Education could make to these practices and procedures.
We focused on Education’s current practices and procedures relating to:
- student protection reporting
- recordkeeping
- maintaining professional judgement.
We acknowledge the work already done to review the circumstances of Kaleb and Jonathon’s interactions with Queensland public sector agencies, including by the Queensland Family and Child Commission.
What we did not investigate
We have not examined the actions or decisions of the National Disability Insurance Agency (the agency that administers the National Disability Insurance Scheme - NDIS) or its engagement with Kaleb and Jonathon. It is a federal agency and therefore outside the Ombudsman’s jurisdiction. A review of the NDIS in 2023 determined that fundamental changes were needed to ensure it was operating as intended.
In addition, we have not investigated the actions of the Queensland Police Service during its various interactions with the family. Operational actions of police officers are outside the Ombudsman’s jurisdiction by virtue of section 7(2) of the Ombudsman Act.
Changes in recent years
There have been several significant changes to the supports and services that were provided to children with disability during Kaleb and Jonathon’s interactions with agencies, including at Education.
In July 2024, the Queensland Government released the Queensland Disability Reform Framework, in response to recommendations made by both the Royal Commission (in its Final Report) and the NDIS Review.
The Queensland Government’s implementation of the recommendations of both the Royal Commission and NDIS Review will understandably take some time. It is yet to be seen what these changes will mean for children with disability in Queensland and their pathways for accessing supports.
Investigation methodology
The investigation was conducted formally under section 24(1)(b) of the Ombudsman Act. We reviewed material from Public Hearing 33 and accepted the evidence presented to the Royal Commission. It has informed the opinions and recommendations set out in this report.
We also:
- considered relevant legislation, including the Education (General Provisions) Act 2006 and the Child Protection Act 1999
- reviewed and analysed material we obtained from Education
- met with representatives from Education
- visited Education to view a demonstration of its information system (OneSchool), with a particular focus on student protection reporting.
We acknowledge the cooperation of the staff of Education and their willingness to provide information and respond to all notices and requests during the investigation.
In the early stages of the Investigation, we met with Kaleb and Jonathon. This gave us the opportunity to engage with them directly; observe their current living environment; and learn about their daily routines, likes and dislikes. We also had the chance to see how they communicate and how support staff are working with them to increase their independence.
Ombudsman's jurisdiction
The Ombudsman is an officer of the Parliament empowered by the Ombudsman Act to:
- investigate administrative actions of agencies on reference from the Assembly or a statutory committee of the Assembly; or on complaint; or on the Ombudsman’s own initiative
- consider the administrative practices and procedures of an agency whose actions are being investigated
- make recommendations to the agency to improve their practices and procedures
- provide information or other help to the agency about ways of improving the quality of administrative practices and procedures.
Under section 18(1)(b) of the Ombudsman Act, the Ombudsman can investigate administrative actions of agencies if the Ombudsman considers they should be investigated. Education is an ‘agency’ for the purposes of section 8 of the Ombudsman Act.
Section 49(2) of the Ombudsman Act outlines the matters about which the Ombudsman may form an opinion before making a recommendation to the principal officer of an agency. These include whether the administrative actions investigated are contrary to law, unreasonable, unjust or otherwise wrong.
Under section 25(2) of the Ombudsman Act, the Ombudsman is not bound by the rules of evidence used in Australian court proceedings.
Instead, the Ombudsman is guided by (although not required to use) the standard of proof used in civil proceedings – the ‘balance of probabilities’. A matter will be proven to be true on the balance of probabilities if its existence is more probable than not.
If the Ombudsman investigates administrative actions on an own-initiative basis, section 52 of the Ombudsman Act allows a report on the investigation to be given to the Speaker for tabling in the Assembly, if the Ombudsman considers it appropriate.
Procedural fairness
The rules of procedural fairness have been developed to ensure that decision-making is both fair and reasonable.
Under section 25(2) of the Ombudsman Act, investigators must comply with these rules when conducting an investigation. If at any time during the course of an investigation it appears that there may be grounds for making a report that may affect or concern an agency, the principal officer of that agency must be given an opportunity to comment on the subject matter of the investigation before the final report is made (section 26(3)).
To satisfy these obligations, we provided the proposed report (which we completed in February 2025) to Ms Sharon Schimming, Acting Director-General of Education. The Acting Director-General responded to the proposed report on 12 March 2025, and we have included the response in its entirety in Appendix B.
We will monitor implementation of the recommendations.
The investigation was not undertaken with a view to making findings about any individual; therefore, the Ombudsman has not formed opinions about any individual’s decisions or actions. Doing so would not allow proper procedural fairness to be extended to the various individuals who may have interacted with Kaleb, Jonathon and Paul Barrett between 2000 and 2020.
This report should not be taken as reflecting adversely on the reputation, competency or integrity of any individual who interacted with Kaleb, Jonathon or Paul Barrett over that period. The focus of the report is on Education’s current practices and procedures relating to student protection reporting, recordkeeping and maintaining professional judgement.
Opinions
In this investigation, we focused on whether Education has practices and procedures that are adequate to prevent the nature and extent of the violence, abuse, neglect and deprivation of human rights that Kaleb and Johnathon experienced from occurring in the future to children with disability.
The policies, practices, procedures and guidelines that we investigated relate to student protection reporting, recordkeeping and maintaining professional judgement. We refer to these resources collectively as ‘practices and procedures’.
The investigation found that Education has implemented a range of practices and procedures to prevent harm to children with disability, and that those practices and procedures have many good features. However, the investigation also identified some problems, such as:
- Education’s current practices and procedures do not include information about what should occur when the outcome of a student protection report is ‘monitor at school’.
- The student reporting process lacks a mechanism to alert staff when multiple reports on a student are being monitored at school.
- Education’s guidance on recordkeeping when suspicions of harm do not meet the reporting threshold is not uniformly consistent across its practices, procedures and training.
- Education’s guidance on recording suspicions of harm that do not meet its reporting threshold means that they are captured only as Records of Contact (notes in Education’s information system) rather than student protection reports, increasing the risk that the information may be overlooked.
- There is insufficiently clear instruction to staff to ensure that repeated incidents of harm, or concerns that recur, are recorded as student protection reports on every occasion.
- The obligation to consider human rights is not included in practices, procedures and training relating to student protection.
- Student protection reports are not audited.
- Education does not currently require information about a disability to be included in a student protection report, despite this being a factor that increases a child’s vulnerability.
- There is a lack of a mechanism in place for schools to consistently receive feedback from Child Safety on the outcomes of student protection reports submitted by Education.
These issues are explored further in the report.
Administrative actions are defined in the Ombudsman Act to include a decision and act, and also a failure to make a decision or do an act. I consider that the above problems in Education’s practices and procedures are administrative actions that are unreasonable for the purposes of section 49(2)(b) of the Ombudsman Act.
I consider Education should take action to rectify these problems, and some of Education’s current practices should be changed, as set out in this report.