Snapshot

In 2023, Public Hearing 33 of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability considered a case study of two children living with disability. They were referred to as Kaleb and Jonathon.

In response to recommendations from the public hearing, the Ombudsman has been investigating some of the public sector agencies that had interactions with Kaleb and Jonathon. We have been considering whether the current practices and procedures of these agencies would prevent other children with disability from experiencing the nature and extent of the harm Kaleb and Jonathon suffered.

From 2004, Kaleb and Jonathon lived with their father, Paul Barrett, in a home managed by the Department of Housing and Public Works (Housing).

During the tenancy of the boys and their father, Housing frequently attended the property for maintenance and repair work. It also occasionally contacted Paul Barrett about the unhygienic state of the property.

Paul Barrett spoke to Housing officers on multiple occasions about the significant care and support needs associated with Kaleb’s and Jonathon’s disabilities, such as their incontinence. He told officers that was why it was difficult to maintain the property.

The Royal Commission identified that Housing did not share information about the condition of the property within its own agency when it could have. The Royal Commission also found that Housing did not share the information with the Department of Families, Seniors, Disability Services and Child Safety when it could and should have.

Housing also identified these issues in reviews it conducted after Paul Barrett’s death.

What we investigated

We examined Housing’s current practices and procedures with regard to its role in identifying and responding to child protection concerns. We found that it provides some guidance to help its officers identify and respond to harm, but we also identified opportunities for improvement.

What needs to be improved

Housing needs to amend some of its current practices and procedures to ensure that its officers identify and respond to child protection concerns, including those that may initially come to their attention as property or tenancy issues. In particular, Housing needs to provide:

  • consistent guidance for officers about when to consult supervisors or managers about a child protection concern
  • child protection training for its officers
  • guidance for officers on how to identify child protection concerns in information received from contractors
  • quality assurance processes for monitoring child protection reporting
  • clearer guidance about recording and reviewing child protection information.

Recommendations

Recommendation 1
Housing amends its current practices and procedures so they all provide consistent guidance to officers about when to consult supervisors or managers in relation to child protection concerns.
Recommendation 2
Housing makes changes to its information management systems so that child protection information recorded during a property inspection automatically replicates in other information management systems about the property and its tenant.
Recommendation 3
Housing amends its current practices and procedures to introduce a step for officers to consult their managers before closing complaints. This could apply to more complex complaints and be determined on a case-by-case basis.
Recommendation 4

Housing amends its current practices and procedures to include a process for officers to assess information received from contractors. This should prompt officers to:

  • inspect the properties contractors have raised concerns about so they can see for themselves the extent of the issues. (This is especially important for concerns that relate to health and safety risks caused by the condition of a property)
  • consider whether the property issues might also be child protection concerns
  • take action in relation to both the property issues and the child protection concerns.
Recommendation 5

Housing amends its current practices and procedures to:

  • explain the differences between its information management systems and how they interact with each other, including how child protection information is flagged in them
  • require officers to review and consider all information management systems in which child protection information may be stored when they are assessing a child protection concern.
Recommendation 6
Housing reviews its current practices and procedures to ensure they clearly and consistently communicate its expectations about when and how to respond to suspicions of harm.
Recommendation 7

Housing amends its current child protection practices and procedures to include:

  • information about its in-house Specialist Response Team, including how to contact it
  • prompts to help officers decide whether they should seek advice from the Specialist Response Team about child protection concerns.
Recommendation 8

Housing develops practices, procedures and training resources for the Specialist Response Team that set out information such as:

  • its purpose and functions
  • the roles and responsibilities of its officers
  • its processes.
Recommendation 9
Housing develops quality assurance processes for how it responds to child protection concerns and includes information about these processes in its practices and procedures.
Recommendation 10
Housing amends its current practices and procedures so they provide information about officers’ obligations to consider human rights when making decisions about child protection concerns. This information should include example scenarios.
Recommendation 11

Housing develops and delivers child protection training that is:

  • targeted at relevant officers (as determined by Housing)
  • conducted at regular intervals
  • attended by staff as required. (This should be monitored.)

1. Introduction

This report is the second 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 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:
    1. the response to the violence, abuse, neglect and deprivation of Kaleb and Jonathon’s human rights
    2. 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
    3. 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 the Department of Education; Queensland Health; the Department of Housing and Public Works (Housing); and the Department of Families, Seniors, Disability Services and Child Safety (Child Safety). 

We want to know if the current practices and procedures will adequately prevent other children with disability from experiencing the violence, abuse, neglect and deprivation of human rights that Kaleb and Jonathon suffered.

However, a Commission of Inquiry into Queensland’s Child Safety System (the Inquiry) started on 1 July 2025. The Inquiry’s terms of reference include the examination of the practices and procedures of Child Safety. Considering the scope of the Inquiry’s terms of reference, the Ombudsman has decided not to proceed further with the investigation into Child Safety while the Inquiry is underway.

The Ombudsman has previously reported on the practices and procedures of the Department of Education. This, our second report, focuses on Housing. 

On 11 October 2023, the Ombudsman gave a notice under section 27(2) of the Ombudsman Act to the Director-General of Housing, 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 issues during Paul Barrett’s tenancy with Housing in order to:

  • identify and assess the current practices and procedures of Housing relevant to ensuring children are safe and protected
  • determine whether these practices and procedures are sufficient to prevent the type of harm that Kaleb and Jonathon experienced 
  • identify improvements Housing could make to its practices and procedures.

We focused in particular on Housing’s current practices and procedures relating to how officers:

  • identify child protection concerns in a public housing context
  • respond to child protection concerns, including reporting them to Child Safety or referring families to support services
  • are trained in identifying and responding to child protection concerns.

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.

We are aware that Queensland public sector agencies interact with the NDIS and provide services to people with disability as part of this scheme. In 2023, a review of the NDIS found that fundamental changes were needed to ensure the scheme was operating as intended.

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 take some time. It is not yet clear what these changes will mean for children with disability in Queensland in future and for the agencies that support them. Our investigation is focused on current practices and procedures.

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.

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
  • reviewed and analysed material we obtained from Housing
  • met with representatives from Housing.

We acknowledge the cooperation of Housing officers throughout 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. Housing 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 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 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 August 2025) to Mr Mark Cridland, Director-General of Housing. The Director-General responded to the proposed report on 19 September 2025, and we have included the response in its entirety in Appendix C. We have also included Housing’s response to recommendations throughout the report and have responded to some of the 
Director-General’s submissions where appropriate.

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 of these individuals.

Opinions

In this investigation, we focused on Housing’s policies, process documents, practices and procedures that relate to identifying and responding to child protection concerns in a public housing setting. We refer to these resources collectively as ‘practices and procedures’.

During the investigation, we identified some issues with Housing’s child protection practices and procedures and asked it to address them. Housing made improvements, but there are still some problems. These include that it:

  • does not provide consistent guidance to its officers about when to consult supervisors or managers about child protection concerns
  • requires officers to record child protection concerns identified during a property inspection in its property inspection system. However, this system does not copy all of this information to Housing’s tenancy management system, which means the information could be overlooked if officers only check in one system
  • does not require officers to consult managers before complaints are closed to make sure child protection concerns are not overlooked 
  • does not have a process for assessing contractors’ issues about properties (such as health and safety risks), which could also be child protection concerns
  • does not provide enough guidance to its officers about 
    • recording child protection information
    • reviewing and considering all information management systems when assessing child protection concerns
  • does not provide consistent information about when and how to respond to concerns about a child
  • does not promote consultation with the in-house Specialist Response Team (which provides advice and expertise to Housing officers about tenants with complex needs) in its child protection practices and procedures in situations where it would be warranted
  • has not developed specific practices, procedures and training resources for its Specialist Response Team
  • does not have quality assurance processes (such as audits) to monitor child protection reporting and referrals to support services (such as Family and Child Connect)
  • does not provide enough guidance to its officers about their obligation to consider human rights when making decisions about child protection concerns
  • does not provide its officers with regular child protection training.

We explore these issues 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. The Ombudsman considers that the above problems are administrative actions that are unreasonable for the purposes of section 49(2)(b) of the Ombudsman Act. 

The Ombudsman considers that Housing should take action to rectify these problems, and that some of its current practices and procedures should be changed, as set out in this report.

2. Housing’s role and responsibilities

Housing has a broad range of responsibilities, including providing affordable housing to eligible Queenslanders through government-owned and managed public housing.

Public housing is in demand. When available, it is offered to those with the highest level of need. Housing defines this as those with particular disadvantage, including people: 

  • with complex health, safety and wellbeing needs
  • who experience significant social or financial hardship, limiting their ability to access housing in the private market.

As of 30 June 2024, Housing managed almost 55,800 tenancies. Of these, 19,500 had at least one child living at the property.

There are 42 housing service centres in Queensland. They are staffed by officers who manage public housing for tenants, help them with housing enquiries, and support their housing needs. 

Housing’s role as a landlord

Housing is the landlord for public housing properties. At the beginning of each tenancy, it must ensure that a property:

  • is clean, fit for tenants to live in and in good repair 
  • complies with health and safety laws and minimum housing standards.

Tenants also have legislative responsibilities, which include keeping the property clean and in good condition for the duration of the tenancy.

Housing has several information management systems that store and manage information about public housing tenancies. They include:

  • a customer management system, which stores information gathered during the assessment of new applications for public housing
  • a tenancy management system, which records information about existing Housing properties and tenancies
  • a property inspection system, which stores information about the inspections of public housing properties and links some of this information to the tenancy management system.

Property inspections

One way Housing meets its obligations as a landlord is by regularly inspecting properties, as detailed in Table 1.

Table 1: Inspections

Type of inspection Frequency Issues to identify  Examples 
Property inspection Once a year

Health and safety issues
  • exposed electrical wiring
  • faulty smoke detectors
  • excessive hoarding, domestic neglect 
    or squalor
  • overflowing sewage
  • serious structural failures.
Tenancy management issues
  •  child protection concerns
  • suspected illegal activity
  • hoarding and squalor
  • suspected undeclared occupants at the home
  • situations where support services or occupational therapists may be required.
Condition appraisal Once every 3 years Condition of the property and required upgrades
  • leaking taps 
  • broken windows or doors
  • peeling paintwork
  • household fittings not in sound condition
  • gutters and roofing that need attention.

Source: Office of the Queensland Ombudsman, adapted from Housing’s current practices and procedures.

Housing has a suite of practices and procedures that guide officers in conducting these inspections. They are available to officers in all housing service centres through Housing Online for Me (HOME), which is Housing’s central online information portal. HOME also contains other operational policies, processes and instructions, as well as resources on topics such as human rights and recordkeeping.

Housing informs its officers about updates to its practices and procedures by posting prominent messages on the main page of HOME. 

The practices and procedures state that officers who conduct property inspections need to undertake special training. 

They also state that officers must record all issues in the property inspection system. Some of these issues may concern child protection.

The Specialist Response Team

In early 2020, Housing established the Specialist Response Team. This team, which is made up of staff with specialist knowledge and expertise, assists Housing officers to support tenants with complex needs, such as those related to:

  • domestic and family violence
  • sexual violence
  • child protection
  • substance abuse
  • mental health
  • complex disability.

The Specialist Response Team can coordinate with and assist Housing officers, at their request, to:

  • deliver housing assistance to tenants with very high and complex needs
  • help tenants access the services and supports they require
  • liaise with tenants and services like the National Disability Insurance Agency (NDIA), Queensland Health, the Office of the Public Guardian, and the Public Trustee
  • respond to child protection concerns.

The Specialist Response Team began operating in early 2020, approximately 2 months before Paul Barrett’s death.

Housing told us its officers would consult the Specialist Response Team if circumstances like Kaleb and Jonathon’s arose today. Officers in the team have:

  • long-term experience working in the disability and/or mental health sectors 
  • experience working with the NDIA
  • knowledge of external agencies and how they work together. 

3. Identifying child protection concerns

 

Between 2004 and 2020, Kaleb and Jonathon lived with their father, Paul Barrett, at a Housing property.

When the family moved into the house, it was clean and undamaged. However, at different times during the tenancy, it was found to be messy, unclean and smelling of faeces and urine.

In 2015, Housing conducted an inspection of Kaleb and Jonathon’s home. Housing officers recorded that:

  • There were holes in the walls and a missing glass panel in a door.
  • The property was sparsely furnished.
  • Kaleb and Jonathon’s bedroom had ‘nothing in it except an inflated double/queen size mattress without any other bedding’.
  • There may have been undeclared occupants living at the property.

Records made after the inspection included a note reading ‘child safety concerns?’ on an internal complaint checklist. The property issues were referred to the relevant housing service centre. Housing did not take any further action in response to the note about child safety concerns. 

In 2019, on 2 occasions, a contractor notified Housing that planned works at the property could not occur due to health and safety concerns. The contractor sent photographs and a video of the house to Housing (see Appendix A) and said that:

  • The property was in a ‘disgusting condition’ and ‘an extremely poor hygienic state’.
  • The stench was overbearing. 
  • They found dog faeces in the house.

In response, Housing officers:

  • asked Paul Barrett to address the concerns 
  • inspected the property and noted that it was being cleaned but still smelled strongly of urine and disinfectant
  • registered 2 complaints as a way to record the issues.

It does not appear that Housing took any further action in response to the hygiene issues. It is also not evident that Housing considered whether they could be child protection concerns.

During Public Hearing 33, Housing acknowledged there were signs the home was in poor condition, but considered there were reasons to explain it. These included Paul Barrett’s statements that Kaleb and Jonathon’s disabilities made it challenging to maintain the property.

However, Housing acknowledged it could have taken more action on several occasions. For example, it said officers could have:

  • escalated their concerns to managers
  • considered whether referrals to support services would have been helpful
  • reported health and safety issues to Child Safety as child protection concerns.

In its report on Public Hearing 33, the Royal Commission concluded that Kaleb and Jonathon: 

  • experienced chronic neglect in their father’s care
  • had inadequate shelter without basic furnishings.

(For more information about Housing’s interactions with the family, see Appendix B.)

In this chapter, we examine the current practices and procedures Housing has developed to help its officers identify child protection concerns. These practices and procedures are stored on Housing’s central information portal, HOME.

We considered these practices and procedures in the context of specific issues that arose in Housing’s dealings with Kaleb and Jonathon, such as:

  • reporting requirements
  • identifying when a child may be in need of protection
  • recognising when issues arising from property inspections, complaints or contractors may be indicators of neglect.

Reporting requirements

Housing’s practices and procedures recognise that Child Safety is the lead child protection agency in Queensland, with statutory responsibility for: 

  • protecting children from harm
  • promoting their safety and wellbeing by making decisions in their best interests
  • supporting families in caring for children.

Housing makes it clear to its officers that they are not responsible for establishing proof or intervening in child protection matters. In its practices and procedures, Housing states that its role is to:

  • support at-risk children and families by providing housing services
  • report child protection concerns.

Housing notes that its officers are not mandatory reporters, such as doctors and teachers (who are required, by law, to report suspicions that a child has been (or is likely to be) harmed). However, Housing expects them to report suspicions of harm under section 13A of the Child Protection Act 1999. This section allows any person to make a report to Child Safety if they reasonably suspect a child may be in need of protection. 

Housing officers also have separate responsibilities, as all adults do, to report child sexual offences in accordance with section 229BC of the Criminal Code Act 1899. These obligations are clearly set out in Housing’s practices and procedures.

Identifying when a child may be in need of protection

Housing states that its officers may identify children in need of protection through: 

  • property inspections and home visits
  • complaints about a tenancy (for example, from neighbours)
  • information from contractors.

Housing’s practices and procedures refer to the factors (in section 13C of the Child Protection Act) that officers should consider when forming a reasonable suspicion that a child is being harmed. These include:

  • whether there are detrimental effects on the child’s body or the child’s psychological or emotional state that are evident to the person (or likely to become evident in the future)
  • the nature and severity of the detrimental effects
  • the likelihood that the detrimental effects will continue
  • the child’s age.

The practices and procedures also state that officers can take into account: 

  • what they see (for example, the physical appearance of a child and their home environment)
  • what they hear (for example, the words children and adults use)
  • information about a child (for example, age, cultural background or disability)
  • parental risk factors (for example, domestic and family violence)
  • information about support services the family may be receiving
  • knowledge about previous Child Safety contact
  • tenancy information (for example, breaches of the tenancy agreement and complaints).

Housing officers are also expected to rely on their training and professional experience.

Housing told us that its information management systems record information about a tenant, including if:

  • they live with disability
  • they have a medical condition that Housing officers should be aware of
  • there are hoarding and/or squalor concerns at the property.

This is important information for officers to consider when assessing child protection concerns. 

Using Child Safety’s Child Protection Guide

Housing instructs its officers to gather all relevant information to help them assess their concerns. It also tells them to use Child Safety’s online Child Protection Guide (the Guide). 

The Guide is intended to complement, not replace, an officer’s professional judgement. It does not prevent them from taking any action they think is appropriate in response to their concerns.

It lists examples of different types of harm, including harm caused through the neglect of a child in their home – as was observed in Kaleb and Jonathon’s case. In a housing context, this harm may be apparent through unsafe or unclean environments, such as:

  • exposed electrical wiring
  • extremely dangerous objects or materials that are accessible to a child (for example, chemicals, guns, knives, medication or illegal substances)
  • structurally unsafe buildings
  • a significant amount of animal or human faeces at a property.

These indicators of harm can be signs that a child may be in need of protection.

Section 10 of the Child Protection Act defines ‘a child in need of protection’ as a child who:
    1. has suffered significant harm, is suffering significant harm, or is at unacceptable risk of suffering significant harm; and
    2. does not have a parent able and willing to protect the child from the harm.

Housing’s practices and procedures include this definition so officers understand what to consider if they identify child protection concerns. 

In addition, they include practical examples of parents who may not be able and/or willing to protect their child. This complements information in the Guide. 

Consulting about child protection concerns 

Some of Housing’s practices and procedures infer that consultation with a supervisor or manager is part of the usual process of determining whether to report concerns to Child Safety.

Other practices and procedures state that it is best practice – but they do not say it is compulsory – for an officer to seek a manager’s approval before reporting to Child Safety. They also state that an officer should make their manager aware they have, or will, make a report.

As a result, it is not clear whether officers are required to consult with managers before making a report to Child Safety, or if it is optional. Housing could improve its guidance to officers about consultation processes by using more direct language.

Recommendation 1
Housing amends its current practices and procedures so they all provide consistent guidance to officers about when to consult supervisors or managers in relation to child protection concerns.

Housing's response:

The department has undertaken a significant amount of work since the commencement of the investigation to review and amend practice and procedural information in the staff portal in relation to reporting child protection concerns to Child Safety and referring a child/family to Family and Child Connect. This work included updating information and communicating changes to staff. 

The department recognises that there are further opportunities to strengthen its guidance for staff through consistent language, defining roles and levels of appropriate delegation (supervisor vs manager), and ensuring staff are applying a consideration lens to the department’s practices and procedures. 

Recognising when property issues may be indicators of potential neglect

Housing officers are in a unique position to identify potential child protection concerns (including abuse or neglect) given their ability to inspect a tenant’s home.

Housing’s practices and procedures state that observations made during inspections, including tenancy management issues, must be recorded in its property inspection system. These include observations regarding:

  • child protection concerns
  • suspected illegal activity
  • hoarding and squalor
  • suspected undeclared occupants at the home
  • situations where support services or occupational therapists may be required.

Officers must record these by selecting a check box in the property inspection system and including comments about the observation. 

If an officer selects a check box, the system automatically sends an email to the tenancy management team at the relevant housing service centre for action. 

We note that a number of tenancy management issues were present in Kaleb and Jonathon’s case. If similar circumstances arose today, Housing’s inspection process would require officers to identify and record these issues as potential child protection concerns. 

We note, however, that information recorded in the property inspection system about tenancy management issues (including child protection concerns) is not automatically transferred across to Housing’s tenancy management system (which contains information about existing tenants). This means that if officers only look in one system, they may not be made aware of relevant issues.

Recommendation 2
Housing makes changes to its information management systems so that child protection information recorded during a property inspection automatically replicates in other information management systems about the property and its tenant.

Housing's response:

The department is committed to continuous improvement across our systems and information sharing platforms to ensure staff have the relevant information required to undertake their role. 

The department acknowledges that there are opportunities to explore what information is currently being transferred between systems, including information from the department’s tenancy management systems that may be relevant for staff undertaking property inspections, and vice versa. This will allow for a broader understanding of the household, and identification of any previous concerns that should be considered by staff.

Additional guidance

Housing provides additional guidance about some tenancy management issues, for example, hoarding and squalor. This includes information about:

  • identifying the signs of hoarding and squalor
  • how hoarding and squalor can affect a tenant and other people living in the house, including children
  • how to support a tenant.

The guidance prompts officers to consider broader factors, such as:

  • the condition of a house and whether it is harmful to a child
  • the behaviour of others in the home, including a child’s parents.

It makes it clear that, among other things, hoarding and squalor could suggest a parent may not be able or willing to protect their child from significant harm.

Housing tells its officers that if they are concerned a child may be at risk of harm as a result of hoarding or squalor, they should consult their manager and consider making a report to Child Safety.

This is an example of Housing providing officers with clear information to support good decision-making and help in identifying child protection concerns. 

Identifying child protection concerns in complaints

Complaints about tenants (for example, by neighbours) are another way Housing can receive information about and identify child protection concerns.

Housing has detailed practices and procedures for responding to tenancy complaints. In these, Housing refers to child protection concerns that may arise in the context of a complaint. For example, officers may receive a complaint about a tenant with young children who is hosting loud parties and engaging in drug activity.

Housing’s practices and procedures state that:

  • These child protection concerns must be dealt with in the same way as if identified by an officer firsthand.
  • A child’s safety must be prioritised.
  • While complainants should be encouraged to report their concerns directly to Child Safety, officers must also consider whether to report the concerns themselves.

The practices and procedures also contain:

  • a prompt for officers to consider whether a complaint includes child protection concerns
  • links to other practices and procedures that explain how to make a report to Child Safety
  • instructions about recording complaints, including the need to make detailed notes about any child protection concerns.

This is appropriate guidance for officers to help them respond to a complaint that may involve child protection concerns.

Housing registered several complaints related to the property Kaleb and Jonathon lived in. On each occasion, the complaint was closed without recording any child protection concerns.

To avoid this occurring in the future, Housing could introduce additional steps in its complaints management process to ensure that child protection concerns are not overlooked. 

Recommendation 3
Housing amends its current practices and procedures to introduce a step for officers to consult their managers before closing complaints. This could apply to more complex complaints and be determined on a case-by-case basis.

Housing’s response:

The department has undertaken considerable work in the management of complaints ensuring that there are appropriate practices and processes in place to support staff to effectively manage tenancy complaints. This work continues to evolve, particularly with the recent introduction of our new Antisocial Behaviour Policy.
The department acknowledges that there are opportunities to strengthen its practice and procedural content further to promote early engagement with other agencies (including Child Safety and the Queensland Police Service) when managing complex complaints. This early engagement can provide a broader understanding of other issues impacting the home that could potentially trigger the need for escalation to a manager, prior to closing out the complaint.
The department will also review current complaints handling training materials, and the role of Divisional complaints coordinators to ensure staff can effectively identify what constitutes a complaint and respond should an escalation be required prior to closing a complaint. 

Identifying child protection concerns from contractors

Housing regularly engages contractors to conduct maintenance work at properties. In the same way that inspection officers can identify issues at a property, contractors may observe issues (for example, health and safety hazards). This happened in Kaleb and Jonathon’s case. 

Housing’s current practices and procedures do not include information to help officers assess contractors’ concerns and determine whether they may also be relevant to child protection. This is problematic. Issues that are a risk to contractors, such as serious health and safety concerns at a property, are equally a risk to tenants and those living with them, including children.

Housing officers need to have adequate guidance to help them identify child protection concerns, whatever the situation. It would be helpful for officers to have guidance on how issues raised by contractors, like those observed in Kaleb and Jonathon’s case, may also be child protection concerns. 

Recommendation 4

Housing amends its current practices and procedures to include a process for officers to assess information received from contractors. This should prompt officers to:

  • inspect the properties contractors have raised concerns about so officers can see for themselves the extent of the issues. (This is especially important for concerns that relate to health and safety risks caused by the condition of a property)
  • consider whether the property issues might also be child protection concerns
  • take action in relation to both the property issues and the child protection concerns.

Housing's response:

The department recognises the ability for contractors accessing properties to identify and raise health and safety matters that could trigger child protection concerns.

The department acknowledges that there should be appropriate mechanisms in place for staff to follow-up and/or address these matters with tenants should they be identified.

The department recognises the opportunity for a strengthening of process when engaging contractors to ensure they report back to QBuild Contract Management if there are potential child safety concerns within a home.

In addition, due to the remote nature of some of the department’s properties, timeframes can vary when inspecting properties should a property issue be raised.

The department will engage with QBuild to understand its current practice and procedures and consider opportunities for improvements from a whole of department perspective in the sharing of information and escalation channels, should concerns be raised by contractors attending departmental properties.

Recording child protection information

Housing’s practices and procedures instruct officers to keep accurate records of child protection information including:

  • reports made to Child Safety
  • discussions with Child Safety about a child
  • information shared with Child Safety.

Housing’s current practices and procedures instruct officers to:

  • record notes against the tenant’s profile
  • select the response option (report, referral or no report)
  • record feedback received from Child Safety about a report.

If Housing officers determine that child protection concerns do not need to be reported to Child Safety or referred to a support service (see Chapter 4), the practices and procedures instruct them to record notes about:

  • the reasons for the decision
  • their consultation with a manager.

The practices and procedures state that a record must only be made once, either in Housing’s customer management system (for new tenants) or its tenancy management system (for existing tenants). Each of these systems has a ‘child protection’ field to capture the information. 

When child protection information is recorded on the customer management system, a flag is displayed. However, it is not clear from the practices and procedures whether the same flag is also visible in the tenancy management system.

When an officer is viewing a tenant’s record in 1 of these 2 information systems, it may not be obvious to them that there is a child protection report or a referral to a support service on the other system.

Housing refers to another information system where additional information about child protection concerns can be saved. However, the practices and procedures do not clearly explain the purpose of this system or how it might link to the other information systems. 

Officers are not instructed to review this system, or the other information systems, when assessing child protection concerns.

We consider that these recordkeeping issues mean that Housing officers: 

  • may not be accessing all of the information related to a particular child protection concern at any one time
  • may overlook important information about a tenant
  • may inadvertently take action (or fail to take action) about a concern because they have not accessed the other information 
  • may not identify past concerns and patterns of harm, including cumulative harm (which is a pattern of repeated abuse or neglect that may have a cumulative and significant impact on a child’s wellbeing and safety).


Recommendation 5

Housing amends its current practices and procedures to:

  • explain the differences between its information management systems and how they interact with each other, including how child protection information is flagged in them
  • require officers to review and consider all information management systems in which child protection information may be stored when they are assessing a child protection concern.

Housing's response:

The department’s position is for this recommendation to be consolidated with recommendation 2. 

Improvements outlined under recommendation 2 would seek to address the concerns as raised as part of this recommendation. 

By addressing the transfer of relevant information as part of recommendation 2 and ensuring the systems interact appropriately, there will not be a requirement to explain the differences between the information management systems.

 

Ombudsman’s comment

The Ombudsman acknowledges Housing’s response to this recommendation. 

As it may take some time for Housing to implement Recommendation 2, the Ombudsman considers it is appropriate for Housing to implement Recommendation 5 in the meantime. This will ensure Housing officers are considering all relevant and available information when assessing child protection concerns. 

4. Responding to child protection concerns

 

Kaleb and Jonathon’s disabilities made it impossible for them to advocate for themselves. They relied on others to ensure they lived in a safe environment where their daily care and support needs could be met. 

In 2004, when Paul Barrett and his sons moved into the property, it was clean and undamaged. At times during the tenancy, Paul Barrett struggled to maintain the property to an acceptable standard. He told Housing that his sons’ disabilities and significant support needs made it difficult for him to keep it clean and hygienic.

Despite this, and the many occasions that Housing officers inspected the property and identified issues, the officers did not escalate concerns about the property within Housing, or make reports to Child Safety. In addition, it is not apparent that Housing referred the family to any support services.

The Royal Commission considered that Housing could and should have done more to protect Kaleb and Jonathon. It also noted the lack of support offered to Paul Barrett, such as help in maintaining the property.

In response to our investigation, Housing told us that if Kaleb and Jonathon’s situation arose today, it would respond differently. For example, it would:

  • work with its Specialist Response Team to assist the family 
  • coordinate and share information with the National Disability Insurance Agency about the children’s health and living conditions and disability support needs
  • contact Child Safety to discuss the family and any concerns
  • address property issues, such as cleaning or repair work.

In this chapter, we examine Housing’s practices and procedures for responding to child protection concerns, again focusing mainly on issues that arose in Kaleb and Jonathon’s case. These include:

  • reporting suspicions of harm 
  • referring a family to support services
  • implementing quality assurance processes
  • considering human rights.

Reporting suspicions of harm

If a Housing officer reasonably suspects that a child is in need of protection, Housing’s current practices and procedures direct the officer to make a report to Child Safety by:

  • contacting Child Safety’s regional intake service, or
  • using Child Safety’s online report form.

The current guidance is generally appropriate, but not always consistent across different practices and procedures.

For example, the majority of them tell officers they should report to Child Safety. However, some state that reports must be made and that the default position (if an officer is uncertain about making a report) is to make a report. 

There is a risk that officers might respond differently to child protection concerns based on the practice or procedure they access. 

Recommendation 6
Housing reviews its current practices and procedures to ensure they clearly and consistently communicate its expectations about when and how to respond to concerns about a child. 

Housing's response:

The department’s view is for this recommendation to be consolidated with recommendation 1. In addition to the review of practices and procedures relating to the escalation of concerns to a supervisor or manager, this review could ensure that the department’s practices and procedures also provide clear guidance about when and how to respond. 

If the recommendations are consolidated, the department will also deliberate on the regularity of information being distributed to staff, giving consideration to current communication channels and training material (including the department’s induction program for new staff).

Ombudsman's comment

The Ombudsman acknowledges Housing’s response to this recommendation.

As each recommendation has a specific focus, the Ombudsman considers it is appropriate that they remain separate. However, it is open to Housing to implement the recommendations in any manner it sees fit. This includes implementing Recommendations 1 and 6 together and communicating the changes to Housing officers at an appropriate time.

Referring a family to support services

In some cases, concerns about a child’s safety can be addressed by offering support to the family. Not every case requires a report to Child Safety. 

The Child Protection Act provides a mechanism for agencies (including Housing) to refer a family to Family and Child Connect. This is a community-based service that helps families by connecting them to appropriate support services, such as Intensive Family Support and Aboriginal and Torres Strait Islander Family Wellbeing Services. 

Family and Child Connect will accept a referral from Housing in circumstances where:

  • there is a risk of a child entering or re-entering the child protection system if they do not receive support
  • the family would benefit from support
  • the family has multiple and/or complex needs.

Housing’s current practices and procedures advise officers to refer a family to Family and Child Connect if:

  • the concerns about the child do not meet the legislative threshold for making a report to Child Safety
  • there is reason to believe the child is likely to be in need of protection if support is not provided. 

Once an officer has decided to make a referral, they are to: 

  • refer the family to Family and Child Connect
  • contact the in-house Specialist Response Team for additional advice if a family is experiencing domestic, family or sexual violence. 

Officers must keep accurate records of referrals made to Family and Child Connect in the same way that they must record other child protection information (discussed in Chapter 3).

We note that Housing also offers guidance to officers if they identify other concerns about a tenancy (not just child protection concerns). Those practices and procedures encourage officers to:

  • check if the tenant receives assistance from any support services 
  • seek consent from the tenant to contact support services to discuss additional assistance.

It is positive to see that Housing has practices and procedures that prompt officers 
to find out if a tenant is receiving support services. From this, officers can determine whether a different type of support may be needed.  

Seeking advice from the Specialist Response Team

As discussed in Chapter 2, Housing established the Specialist Response Team in 2020, shortly before Paul Barrett died. Its staff have specialist knowledge and expertise, and assist Housing officers to support tenants with complex needs.

Housing’s practices and procedures encourage its officers to seek advice from the Specialist Response Team in particular situations, for example, where:

  • there is hoarding and squalor at a property
  • tenants may be experiencing domestic and family violence
  • tenants with disability may need support.

Kaleb and Jonathon had significant care and support needs, and their home was in a poor state. Officers who were involved at that time would likely have benefited from the advice of specialist staff like those in the Specialist Response Team.

Housing told both us and the Royal Commission that its officers would work with the Specialist Response Team if a situation like Kaleb and Jonathon’s arose today. 

However, we note that Housing’s current child protection practices and procedures do not promote consultation with the Specialist Response Team, except if the concerns relate specifically to domestic and family violence. We consider this a missed opportunity. 

 
Recommendation 7

Housing amends its current child protection practices and procedures to include: 

  • information about its in-house Specialist Response Team, including how to contact it
  • prompts to help officers decide whether they should seek advice from the Specialist Response Team about child protection concerns.

Housing's response:

The department’s view is for this recommendation to be consolidated with recommendation 8 … The SRT is well established within Housing and Homelessness Services, including being co-located with the Fortitude Valley Housing Service Centre. Housing Service Centre staff contact senior staff in the SRT, comprising five permanent and three temporary/limited term staff, to seek guidance regarding issues of concern regarding children, including in domestic and family violence situations, or children living in public housing properties with hoarding and squalor or where staff are considering seeking assistance from Child Safety to inform housing assessment, allocation or tenancy management.

When assistance is sought by frontline housing staff, it is SRT’s role to assist staff with information about making a Child Safety report and to help navigate or escalate matters as required. 

The department acknowledges that despite the SRT being a well-established team within the department, there are opportunities to consider strengthening process and practice material, including promoting the facility to contact the SRT for guidance if required. The department can further consider ensuring there is visibility of the role and responsibilities of the SRT in training and induction material as appropriate. 

Ombudsman's comment
It is pleasing to see that Housing is open to further promoting the work of its Specialist Response Team. If Housing makes the recommended changes to its practices and procedures, it should ensure that the Specialist Response Team is appropriately resourced to meet any increase in demand for its assistance.

During the investigation, we identified that the Specialist Response Team does not have its own practices and procedures. Housing explained that the team uses the same practices and procedures as the officers who are employed in housing service centres. 

We found this surprising, given the distinct role of the Specialist Response Team (described in Chapter 2).

Having specific practices and procedures for the Specialist Response Team would:

  • help officers in that team to understand their roles and responsibilities
  • promote accountability and consistency in decision-making
  • clarify for Housing officers the difference between their role and that of the Specialist Response Team in relation to responding to child protection concerns. 
Recommendation 8

Housing develops practices, procedures and training resources for the Specialist Response Team that set out information such as:

  • its purpose and functions
  • the roles and responsibilities of its officers
  • its processes.

Housing's response:

The department’s view is for this recommendation to be consolidated with recommendation 7 as per above.

Ombudsman's comment

Recommendations 7 and 8 are aimed at addressing different issues. 

Recommendation 7 is focused on strengthening the practices and procedures that support Housing officers in responding to child protection concerns.

Recommendation 8 is focused on developing practices and procedures to support staff in the Specialist Response Team. For this reason, the Ombudsman considers it is appropriate that the recommendations remain separate.

Implementing quality assurance processes

It is not enough to have practices and procedures that outline how to identify and respond to child protection concerns. They must be implemented as required. 

An agency needs to have processes in place to monitor how officers comply. This allows it to analyse its performance, ensure consistency across decision-making and make improvements where needed.

Housing’s current practices and procedures relating to child protection do not refer to any quality assurance processes. This is an area for improvement.

For example, Housing could conduct audits of child protection reports made to Child Safety and referrals sent to support services. This would allow it to identify whether officers are appropriately assessing child protection concerns and responding to them in accordance with current practices and procedures.

Housing told us it is making changes to its information management systems to increase oversight of child protection reports made by officers. We encourage Housing to continue this work, as it will help it to:

  • review its officers’ decision-making
  • better understand the needs of its tenants, including those who are most vulnerable.
 
Recommendation 9
Housing develops quality assurance processes for how it responds to child protection concerns and includes information about these processes in its practices and procedures. 

Housing's response:

The department acknowledges the importance of quality assurance processes and recognises the opportunity to review the processes and practices undertaken by staff in managing child protection concerns. 

As part of the current work sampling program, the department will consider a regular review of these processes and practices focusing on providing assurance of the quality and consistency of service delivery, minimising risk, promoting best practice and innovation, and driving continuous improvement. Outcomes from these reviews are shared with leaders and their teams across the state, and utilised to enhance our policies, system, practices and learning and development. 

Considering human rights 

The Human Rights Act 2019 commenced in its entirety in January 2020, so it was not in effect during most of Paul Barrett’s tenancy with Housing. However, it is now relevant to the decisions Housing officers make. 

As officers of a public sector agency, Housing officers are required to act and make decisions in a way that is compatible with human rights, and to properly consider human rights when making decisions. 

One of these rights relates to the protection of families and children. Section 26(2) of the Human Rights Act states: 

Every child has the right, without discrimination, to the protection that is needed by the child, and is in the child’s best interests, because of being a child.

Other human rights may also be affected by child protection decisions, depending on the circumstances.

Housing’s practices and procedures

Housing has many resources on HOME (Housing’s central online information portal) relating to human rights. Its child protection practices and procedures link to these resources, and Housing told us that it also delivers training to officers about human rights.

The resources are detailed and help officers to properly consider human rights in decisions about tenancies and tenants. They include information about:

  • Housing decisions that may be relevant to each human right
  • how officers can make decisions that are compatible with human rights
  • handling complaints about human rights breaches
  • recording human rights considerations and decisions.

Housing’s child protection practices and procedures make it clear that officers must record human rights considerations at the same time as documenting a decision to report to Child Safety or to refer a family to Family and Child Connect.

However, we note there is limited guidance about what these human rights considerations may look like in real life (for example, when making a decision to report a child to Child Safety). This could be improved.

 
Recommendation 10
Housing amends its current practices and procedures so they provide information about officers’ obligations to consider human rights when making decisions about child protection concerns. This information should include example scenarios. 

Housing's response:

The department recognises the importance of ensuring staff are applying a human rights consideration lens when managing child protection concerns and will consider further opportunities to strengthen its guidance for staff throughout practice and process material.

5. Training in child protection

Housing does not deliver mandatory child protection training to its officers. 

During the investigation, Housing informed us that many of its officers attended a child protection training session in September 2024. It was designed with Child Safety and covered a range of topics, including:

  • indicators of child abuse and neglect, such as environmental indicators (for example, locks on doors, squalor and damage to property)
  • information to prepare before making a child protection report (with tips on providing as much detail as possible)
  • responding to a child who discloses they have been harmed 
  • reporting new or additional concerns to Child Safety
  • how to contact Child Safety’s after-hours service centre
  • recordkeeping, including advice about recording relevant, factual information.

It is encouraging that Housing worked with Child Safety to develop a child protection training session tailored for Housing officers. We consider that it should deliver this type of training to its officers regularly. It would help them to: 

  • identify and respond to child protection concerns
  • understand their obligations as Housing officers (as distinct from Child Safety or Queensland Police Service officers)
  • develop their professional judgement
  • make consistent decisions.

Housing must ensure any child protection training delivered to its officers aligns with its practices and procedures. 

Recommendation 11

Housing develops and delivers child protection training that is:

  • targeted at relevant officers (as determined by Housing)
  • conducted at regular intervals 
  • attended by staff as required. (This should be monitored.)

Housing’s response:

The department will engage with Child Safety with the intent of developing a co-designed training program for staff in both agencies dealing with child protection concerns. The department has well established mechanisms in place for managing training completion rates for staff across the state. Any newly developed training material will include monitoring and evaluation mechanisms.

Housing advised us that it delivers training to officers on other, related topics. We note that some of these topics are also relevant to responding to child protection concerns. They include:

  • unconscious bias, particularly in relation to people with disability
  • disability awareness
  • approaches to trauma-informed care
  • hoarding and squalor
  • human rights.

We acknowledge Housing’s work on training its officers to improve how they identify and respond to child protection concerns. 

 

Appendices

Appendix A: Photographs of the house Kaleb and Jonathon lived in (PDF 245KB)

Appendix B: Housing's interactions with Kaleb, Jonathon and Paul Barrett (PDF 59.9KB)

Appendix C: Response from the Department of Housing and Public Works (PDF 374KB)