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:
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 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.