Caution:
This site includes information about child deaths, which some readers may find distressing. If you need support, free and confidential help is available.
We wish to convey our sincere condolences to the families and friends of the infants, children and young people in NSW who have died. It is our foremost responsibility to learn from these deaths and to use that knowledge to make a difference.
Every child's death is a profound loss. The CDRT was established to learn from these losses — to understand what happened, why it happened, and how similar deaths can be prevented.
We record, analyse, and report on the deaths of children and young people across the state. By studying long-term patterns and identifying risks, we help inform laws, policies, and services that protect children and support families.
We are established under Part 5A of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (NSW).
A society that values and protects the lives of all children, and in which preventable child deaths are eliminated.
To eliminate preventable child deaths in New South Wales by working collaboratively to drive systemic change based on evidence.
Each of our functions helps us better understand why children die in NSW, and turn that knowledge into prevention and system improvement.
The NSW Ombudsman maintains the Register of Child Deaths on behalf of the CDRT. It records information about every child and young person under 18 who has died in NSW since 1996, except as a result of stillbirths.
The NSW Registry of Births, Deaths and Marriages notifies the Ombudsman of each death. Additional details come from agencies such as NSW Health, the Department of Education, the Department of Communities and Justice, NSW Police, the Coroner, and other relevant government and non-government services.
This information provides valuable insight into the circumstances of each death, helping us learn from them and strengthen systems that keep children safe.
We analyse the data collected through the Register to understand patterns, risk factors, and emerging issues.
The data includes age, location, cause of death, social context, and any child protection history. We classify each death using the International Statistical Classification of Diseases and Health Related Problems, 10th Revision, Australian Modification (ICD-10-AM) and examine the data to reveal differences across regions, age groups, and causes.
This helps us understand which children are most at risk, and where prevention efforts can have the greatest impact.
Research underpins everything we do. We undertake and commission research independently and with partners to expand knowledge and guide prevention.
Our Research Framework ensures each project meets high ethical and scientific standards, includes Aboriginal and Torres Strait Islander perspectives, and focuses on practical, evidence-based outcomes that lead to real-world change.
We make evidence-based recommendations to government and community organisations to help improve laws, policies, programs, and services that affect children.
Each year, we monitor progress on our recommendations to assess whether they have been implemented or substantially achieved.
We then decide whether to:
Our assessments of progress and decisions about each recommendation are reported publicly in our annual reports.
This ongoing process ensures our insights translate into tangible improvements in child safety and wellbeing.
We report directly to the NSW Parliament through:
These public reports make our work transparent and accountable, providing data and insights to support change.
The NSW Ombudsman is an independent integrity agency that promotes fairness and accountability in public administration and community services.
The Ombudsman convenes and supports the CDRT, managing its day-to-day operations, such as:
Under Part 6 of the same Act, the NSW Ombudsman also reviews the deaths of children who died in care, detention, or in circumstances of abuse or neglect.
These are known as reviewable child deaths. The Ombudsman’s reviews under Part 6 complement the CDRT’s functions under Part 5A, providing a more complete understanding of child deaths in NSW and helping to inform prevention across government and community services.
The CDRT brings together experts in child health, development, protection, and research, who all contribute valuable cultural and professional insights. It includes representatives from NSW Health, NSW Police, NSW Coroner, the Department of Education, and the Department of Communities and Justice. It also includes Aboriginal representatives and independent experts. The Minister responsible for the Act appoints the members, and the NSW Ombudsman serves as the Convenor.
Mr Paul Miller PSM - (Convenor) NSW Ombudsman
Mr Chris Clayton - Community Services Commissioner / Senior Deputy Ombudsman
Ms Zoe Robinson - NSW Advocate for Children and Young People
Alison Sweep - Director Engagement and Family Support, Department of Communities and Justice
Amy Vincent-Pennisi - Coronial Information and Support Program Coordinator, NSW State Coroner
Anne Reddie - Director, Child Wellbeing and Mental Health Services, Student Support and Specialist Programs, Department of Education
Dr Helen Goodwin - Chief Paediatrician/Senior Clinical Advisor Paediatrics, NSW Health; Senior Staff Specialist Paediatrician, Royal North Shore Hospital
Detective Superintendent Joseph Doueihi - Commander Homicide Squad, State Crime Command, NSW Police Force
Sarah Bramwell - Director, Practice Learning, Office of the Senior Practitioner, Department of Communities and Justice
Vanessa Chan - Director, Criminal Law Specialist, Department of Communities and Justice
Dr Bronwyn Gould AM - General Practitioner
Professor Ilan Katz - Professor Social Policy Research Centre, University of NSW
Jennifer Black - Commissioner, Mental Health Commission of NSW
Kathleen Clapham AM, Professor - Professor (Indigenous Health), School of Medical, Indigenous and Health Sciences; Director, Ngarruwan Ngadju First Peoples Health and Wellbeing Research Centre, University of Wollongong
Dr Lorraine Du Toit-Prinsloo - Chief Forensic Pathologist and Clinical Director, Forensic Medicine Newcastle, Forensic & Analytical Science Service, NSW Health Pathology
Dr Luciano Dalla-Pozza - Head of Department (Cancer Centre for Children), Senior Staff Specialist (Paediatric Oncology), The Children’s Hospital at Westmead
Dr Matthew O’Meara - Senior Staff Specialist Paediatric Emergency Medicine, Sydney Children’s Hospital Randwick
Ngiare Brown, Professor - Chancellor, James Cook University; Chair, National Mental Health Commission Advisory Board; Director and Program Manager, Ngaoara Child and Adolescent Wellbeing; Executive Manager Research and Senior Public Health Medical Officer, National Aboriginal Community Controlled Health Organisation; Professor of Indigenous Health and Education, University of Wollongong
Dr Susan Adams - Senior Staff Specialist, General Paediatric Surgeon and Head of Vascular Birthmarks Service, Sydney Children’s Hospital; Associate Professor, School of Women’s and Children’s Health, University of New South Wales
Dr Susan Arbuckle - Paediatric/Perinatal pathologist, The Children's Hospital at Westmead
The CDRT is part of the Australian and New Zealand Child Death Review and Prevention Group (ANZCDR&PG), a collaboration of child death review teams from across Australia and New Zealand. Every year, the ANZCDR&PG comes together to share information and insights to better understand and prevent child deaths.
The other ANZCDR&PG members are:
Reducing child deaths requires collective effort. Our strength lies in collaboration, sharing data, expertise, and insights across agencies and research partners to drive action that improves outcomes for children and families.
Together, we’re working towards a safer, more equitable future for all children in NSW.