Understanding the challenges for South Australian Aboriginal families and children: What can child death reviews contribute?

Content type
Short article

September 2016

This article was written by The South Australian Child Death and Serious Injury Review Committee.

The death of a child is considered to be a sentinel event from which we can learn.1

In South Australia, Aboriginal children are three times more likely to die than non-Aboriginal children. The South Australian Child Death and Serious Injury Review Committee noted from its register of post-partum deaths that Aboriginal infants up to 28 days of age are twice as likely as non-Aboriginal infants to die from natural causes. This rate rises to five times higher in the broader postnatal period (28 days to one year of life). This article discusses the role of the South Australian Child Death and Serious Injury Review Committee and provides an example of the Committee’s work concerning the deaths of Aboriginal infants.

The South Australian Child Death and Serious Injury Review Committee reviews and collects statistical information about all children who have died in the state. The Committee comprises independent and Government members from a range of fields, including psychology, law, health and community services. It is established under the South Australian Children’s Protection Act 19932 and its main functions are to: 

  • review cases in which children die or suffer serious injury with a view to identifying legislative or administrative means of preventing similar cases of death or serious injury in the future; and
  • make and monitor the implementation of recommendations for avoiding preventable child death or serious injury.

An example of the Committee’s work concerning the deaths of Aboriginal infants 

The committee conducted an in-depth review of services provided to six very young Aboriginal babies and their parents. The six babies died in circumstances that included premature birth, maternal health problems during pregnancy and labour, and infant health problems observed in the postnatal period. Poor nutrition and use of tobacco, alcohol, and other substances were noted in the lives of all of the mothers, as were financial and housing difficulties, and family violence. Most of the mothers lived in rural or remote settings and few had received adequate antenatal care. 

The Committee therefore recommended that the South Australian Department of Health:

  • act immediately to deliver an integrated prenatal and postnatal service to Aboriginal women; and
  • demonstrate how such a service will be provided to women in remote areas of the state, given that most of these mothers lived in rural and remote settings.

The Committee will be monitoring the Department’s response. 

For further examples of the Committee’s work, please see its Annual Reports.

Contact Person: Rosemary Byron-Scott: [email protected]

The Child Death and Serious Injury Review Committee extends its condolences to the families and friends who have experienced the death of a child and to the communities and professionals who cared for them.


1. Fraser, J, Sidebotham, P, Frederick, J, Covington, T, Mitchell, EA. (2014). Learning from child death review in USA, England, Australia and New Zealand. Child death in high income countries. The Lancet. 384:894-903

2. Children’s Protection Act 1993

Further reading and resources

The following publications and resources have been compiled by the Australian Institute of Family Studies.

Knowledge Circle

To learn more about what works to help keep Aboriginal and Torres Strait Islander children safe and happy in their communities, visit the Knowledge Circle website. You will find Practice Profiles, discussion articles and a range of culturally appropriate practice and evaluation resources.

Reports and articles

See also relevant papers from the Closing the Gap Clearinghouse, delivered in partnership between AIFS and Australian Institute of Health and Welfare (AIHW):

The feature image is by Matthias Mutz, CC BY-NC-SA 2.0