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Public hearing 33 - Violence, abuse, neglect and deprivation of human rights (a case study) - Day 3

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COMMISSIONER McEWIN:  Good morning, everyone. We welcome everyone who is attending the Public hearing in the Royal Commission Brisbane hearing room, as well as those following the proceedings on the live stream. This is the third and last day of Public hearing 33 of the Royal Commission. I will now invite Commissioner Mason to do the Acknowledgement of Country. 

COMMISSIONER MASON:  Thank you, Chair. We acknowledge Meanjin, Brisbane.  We recognise the country north and south of the Brisbane River as the home of both Turrbal and Jagera nations. We acknowledge the Turrbal and Jagera nations as the traditional custodians and owners of the lands upon which this Royal Commission is sitting. We acknowledge and pay our deep respects to Elders past and present, and we acknowledge First Nations young people who one day will take their place as Elders. We extend that respect to all First Nations people and acknowledge their enduring connection to land, sky, seas and waterways. We pay our deep respect to First Nations people here today and who are following this Public hearing online on the mainland and on the islands, including Tasmania and in the Torres Strait, especially Elders, parents and young people with disability. Thank you, Chair. 

COMMISSIONER McEWIN:  Thank you, commissioner Mason. Before I hand over to Counsel Assisting, Ms Eastman, I would like to remind those viewing this hearing that there are non publication and pseudonym directions which apply to certain evidence. The two young men who are the focus of this hearing are referred to by pseudonyms Kaleb and Jonathon. The Royal Commission has made directions prohibiting publication of their names and identifying information in relation to this hearing. Ms Eastman. 

MS EASTMAN:  Thank you, Commissioner McEwin, and good morning, Commissioners, and good morning to everybody in the room and those following what will be the final day of the Royal Commission's substantive hearings. Could I also remind people following today's hearing that there will be content that people may find distressing, triggering, upsetting or cause them worry or concern, and the numbers that came up on the screen with our content warning earlier this week continue to be available to people if they require any assistance and support, and we also have members of our counselling team present here at the Royal Commission today. 

Commissioners, today we turn our attention to six witnesses representing various Queensland departments and agencies who, over the course of a period of around 20 years, interacted with Kaleb, Jonathon and their father. Each brings slightly different perspectives to the nature and the extent of their interaction with the family, but all played a material and important role in providing safety and welfare and wellbeing to the lives of Kaleb and Jonathon. 

In terms of the organisation of the day, we thank everybody for starting early and bearing with us with the early start. The plan at this stage would be to take the first two witnesses and then adjourn for morning tea. Following morning tea, there will be a further witness, and towards the end of that witness's evidence, Commissioners, there will be a part of his evidence which will be taken in a closed session. There's some material that we need to show the witness in the hearing room that is part of the confidential material, and so we will be kindly asking those people who are not representing a party with leave to appear or otherwise staff at the Royal Commission to vacate the hearing and that there will be a period of time where they may have a longer lunch than us, but that we will take that evidence in a closed session, and then following lunch, I think, will be the remaining three witnesses. 

All being well, Commissioners, we hope to conclude sometime around 3.30 this afternoon, but often my estimates of time are not always the most accurate, but we've prepared on the basis that we'll do that. So, our first witness is Dr Meegan Crawford. You can see she's here with us in the hearing room and I understand will take an affirmation. Thank you, Dr Crawford. 


COMMISSIONER McEWIN:  Thank you, Ms Eastman.  Dr Crawford, thank you for coming and for providing your forthcoming evidence and also for the material that you've provided to us. I'm Commissioner McEwin. This is Commissioner Mason and Commissioner Ryan. I will ask the associate, who is down here, to   to your right   to read out to administer the affirmation. Thank you. 

THE ASSOCIATE:  I will read you the affirmation. At the end, please say yes or I do. Do you solemnly and sincerely declare and affirm that the evidence which you shall give will be the truth, the whole truth and nothing but the truth? 



COMMISSIONER McEWIN:  Thank you.  Ms Eastman will ask you some questions. 


MS EASTMAN:  Thank you, Dr Crawford, and welcome back. You appeared at the Royal Commission's hearing in Brisbane in Public hearing 8 a couple of years ago; is that right?

DR CRAWFORD:  I did, yes. 

MS EASTMAN:  So you've provided to the Royal Commission a statement.  You've got a copy of the statement with you. 

DR CRAWFORD:  Yes, I do. 

MS EASTMAN:  And the statement was made, I think, on 5 May; is that right? 

DR CRAWFORD:  Yes, that's right. 

MS EASTMAN:  And have you had an opportunity to read over the statement? 


MS EASTMAN:  And the contents of the statement are true and correct? 


MS EASTMAN:  Last time you appeared, you were representing the Department of Children, Youth Justice and Multicultural Affairs. 


MS EASTMAN:  Do you mind, for convenience's sake, if I refer to the department by its old name, Child Safety? 

DR CRAWFORD:  Certainly. 

MS EASTMAN:  So if I refer to Child Safety, I'm referring to the department but I mean no disrespect in terms of the current name of the department. Your substantive role in the department is Chief Practitioner; is that right? 

DR CRAWFORD:  That's right. 

MS EASTMAN:  And in terms of your history with the department, it goes back to a period of time in 2005; is that right? 

DR CRAWFORD:  Yes, that's right. 

MS EASTMAN:  So you've had a period employed by Griffith University as a researcher, and then you came back to the department in 2011; is that right? 

DR CRAWFORD:  That's right, but I did start with the department in 1991. 

MS EASTMAN:  Alright. So, if you've got a copy of your statement there, I want to start with some of the matters that you've identified in what you've described as background. But before I do that, do you recall at Public hearing 8 some evidence given by Professor Darrell Higgins? 

DR CRAWFORD:  I know Darrell Higgins.  I'm not aware of the evidence that he provided. 

MS EASTMAN:  You don't recall the evidence that he gave at that time? 

DR CRAWFORD:  No, I don't. 

MS EASTMAN:  Right.  Dr Higgins   and, Commissioners, the Higgins evidence, if you need a reference, is Exhibit 8007. Professor Higgins, on that occasion, talked about the model of child protection adopted in Australia's States and Territories as focused on something described as tertiary child protection. You've heard that expression, haven't you? 

DR CRAWFORD:  Yes, I have. 

MS EASTMAN:  And that the orientation of child protection systems towards tertiary responses means that they are oriented towards assessing risks to children reported to a Child Safety agency. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  Often by a mandatory reporting obligations. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And managing identified risks of harm. So, that's what he said. Do you agree with that characterisation? 


MS EASTMAN:  And this orientation is reactive. 

DR CRAWFORD:  Reactive? 

MS EASTMAN:  Reactive in the sense, would you agree, that if the tertiary approach is responding to incidents or matters reported, then the approach is one dependent on responding or reacting to those reports? 

DR CRAWFORD:  Yes. It   we do respond and we do have a legislative definition for child protection notifications. So, there are a number of different ways that we can respond to concerns that are presented to us. So, we might record an intake inquiry, which is a general inquiry. We might record a child concern report, which means that there is some harm identified for the child but we do not believe that that's at a significant harm level. 

MS EASTMAN:  I want to come back to that definition of harm   

DR CRAWFORD:  Certainly. 

MS EASTMAN:    in a moment, but just really setting the scene, do you agree with me that the model is one that primarily works to reaction. It's reacting to events reported to it? 

DR CRAWFORD:  We respond to significant harm and a reasonable suspicion that children are in need of protection. 

MS EASTMAN:  And Dr Higgins expressed the view to the Royal Commission that he was not aware of any systemically funded evidence based child maltreatment prevention and early intervention programs and services that are widely accessible to the majority of families. Do you have any knowledge of whether there are systemically funded evidence based child maltreatment prevention and early intervention programs available to families? 

DR CRAWFORD:  There is a difficulty in the evidence base for programs. The Queensland Government certainly funds a number of secondary services, so prevention or secondary supports which should assist families and divert them from the tertiary child protection system. 

MS EASTMAN:  Alright. I want to take you now to paragraph 5 of your statement. 


MS EASTMAN:  And can I ask you this:  you've been careful in your language in that paragraph, haven't you? You've carefully thought what you wanted to include   


MS EASTMAN:    in that paragraph? 


MS EASTMAN:  And you wanted to emphasise that the department acknowledges that on occasions over 20 years history with the family, practitioners could be perceived as overestimating the father's capacity to mitigate risks present and provide for his children's needs.


MS EASTMAN:  So you thought carefully about using the language ‘could be perceived’; is that right?

DR CRAWFORD:  Yes, I have. 

MS EASTMAN:  You've had an opportunity to read the proposed statement of facts. 

DR CRAWFORD:  Yes, I have. 

MS EASTMAN:  You've also had an opportunity to review the department's records; is that right? 

DR CRAWFORD:  I have, yes. 

MS EASTMAN:  Would you agree with me that using the expression ‘could be perceived’ seeks to minimise or diminish the impact in which the practitioners overestimated the father's capacity to mitigate the risks present? 


MS EASTMAN:  Are you suggesting, by the word ‘perceived’, that there the practitioners' conduct can be explained away based on perception? 

DR CRAWFORD:  I think when I reviewed the file I could see some very rigorous assessments of this father and the impacts on the children, and I could see that there were periods of time where we intervened actively with him, where we referred to other services, and where we did see improvements for the family over time. I undertake a number of reviews for the department and   

MS EASTMAN:  I just want to concentrate on what you've put in paragraph 5 and why you've chosen to say it ‘could be perceived’ rather than stating directly that the practitioners did, in fact, overestimate the father's capacity to mitigate risks present and provide for his children. Because it is the fact, isn't it? 

DR CRAWFORD:  I'm always conscious of hindsight bias and the privilege of being able to look back at information, and I always feel for our staff in the moment, so   

MS EASTMAN:  Well, let me preface my questions by saying, I am not asking the Royal Commission to make any adverse findings against any particular Child Safety Officer   

DR CRAWFORD:  Thank you. 

MS EASTMAN:    on a given date. So, let's start with that as an agreement. 

DR CRAWFORD:  Thank you. 

MS EASTMAN:  But this Royal Commission is looking in this case study at a life course approach to understand why and how violence, abuse, neglect, and the deprivation of two children with disability and their life course. So, that's the context in which I'm asking the questions. 


MS EASTMAN:  So, in that context, if we do take the opportunity of reflecting back, looking at the particular incidents, looking at the records, you'd agree that provides an opportunity to learn   


MS EASTMAN:    what the patterns were. 


MS EASTMAN:  What the life course influences were, where there are gaps   you agree? 


MS EASTMAN:  Whether the model is one essentially based on reaction rather than prevention. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  We have the opportunity to do that, don't we, by reflecting back? 

DR CRAWFORD:  Yes, we do. 

MS EASTMAN:  And you'd agree with me reflecting back to suggest that it could be no higher than it ‘could be perceived’ as overestimating the father's capacity to minimise risks and prevent   and provide for his children's needs, that seeks to minimise the collective evidence available. Would you agree with that? 


MS EASTMAN:  You've included in your evidence in paragraph 6 and following some references to Dr Andrew Whittaker's work. 


MS EASTMAN:  And I think you've now got a copy of the two articles that are referred to in footnote 1 and footnote 2 of your statement. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  The first one is an article that was published based on Dr Whittaker's evidence to a Coronial inquiry here in Queensland. You agree with that? 

DR CRAWFORD:  Yes, that's right. 

MS EASTMAN:  And you've read the report. 

DR CRAWFORD:  Yes, I have. 

MS EASTMAN:  And tell me if you disagree with any of the summaries that I want to make. Just with the time available I'm not going to walk you through the detail of the Whittaker report. But essentially what he said in his evidence to the Coronial hearing is that child protection and Child Safety officers can often operate with a level of what is described as unconscious bias. 


MS EASTMAN:  And the nature of unconscious bias reflects   and it's a term, but it reflects those thought patterns that are often instinctive or reactive. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And understanding unconscious bias is to understand that the way in which we sometimes approach situations is   and I'll use the way in which Professor Danny Kahneman describes, if that's helpful   is that our brains often work on what is often called fast and slow thinking. 


MS EASTMAN:  Fast thinking is the immediate responsive immediate conclusions that we make without taking the time to slow our thinking down and go through the logical process of assessing evidence and taking the slow steps forward. 


MS EASTMAN:  If I can illustrate it this way, Commissioners, and this is how Professor Kahneman describes the approach to unconscious bias, is if we ask people in the room what the answer to two plus two is, we don't really need to think about that.  We know the answer. But if I ask people in the room, with the exception of mathematicians and those with a calculator, what 2033 multiplied by eight might be, we can all do that exercise, but it requires a slower form of thinking. 


MS EASTMAN:  So we would take the slow thinking to step through the processes to reach the answer. So, unconscious bias reflects the mode of thinking which is reactive, and it's often based on the way in which we, use in our cultures, in our behaviours, in our language and in our patterns, things that we're used to. Dr Whittaker in his report talks about the unconscious bias for Child Safety officers looking always to be optimistic and to hope for the best. 


MS EASTMAN:  Do you agree with that? 


MS EASTMAN:  And he says that that can result in an unconscious bias where the Child Safety officers predominantly focus on the positive, that they may seek to overestimate or overweigh the evidence of a parent who might express love for a child. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  A parent who might be professing to do their best. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And if a parent makes some improvements, then a lot of weight may be given to the outcome of the improvement, and the consequence might be, in the way the unconscious bias operates, is to minimise the negative or dangerous factors. Do you agree with that? I'm really summarising. 


MS EASTMAN:  So bear with me if you think any part of that summary is not accurate. 

DR CRAWFORD:  Ms Eastman, we do train our staff in these biases, because we are conscious. So, the professor that you quoted and the thinking fast, thinking slow, is part of the training that we provide to Child Safety officers, and one of the reasons we have a supervision policy and employ more experienced practitioners as Team Leaders is so that Child Safety officers can reflect on their practice, can reflect on their assessments and can be challenged about their thinking by a more experienced officer. 

MS EASTMAN:  Did the initiatives in relation to addressing unconscious bias in training come in in recent times? 

DR CRAWFORD:  I couldn't tell you the exact date. 

MS EASTMAN:  Let me put it this way:  didn't exist in 2000, did it? 


MS EASTMAN:  It didn't exist in 2010. 

DR CRAWFORD:  Probably not. 

MS EASTMAN:  And it probably didn't exist in 2019. 

DR CRAWFORD:  Yes, it would have existed in   

MS EASTMAN:  You would have had it by then.


MS EASTMAN:  But you can't remember exactly when   

DR CRAWFORD:  No, but I could get that for you. 

MS EASTMAN:  And Dr Whittaker made a number of recommendations as part of his evidence to the Coronial inquiry. Did the Department of Child Safety act on any of those particular recommendations? 

DR CRAWFORD:  All of them, yes. 

MS EASTMAN:  And would that have informed any work Child Safety now does to address unconscious bias? 


MS EASTMAN:  And you haven't referred to any training on unconscious bias in this statement, have you? 

DR CRAWFORD:  No, I haven't. 

MS EASTMAN:  And you haven't addressed whether the department had reacted or responded to any of Dr Whittaker's recommendations. You agree with that? 

DR CRAWFORD:  I agree. 

MS EASTMAN:  When we're talking about unconscious bias in relation to the relationship between parents and child in a child protection setting, to what extent does the unconscious bias attaching to people with disability, and particularly intellectual disability, arise? 

DR CRAWFORD:  Sorry, could you repeat that question? 

MS EASTMAN:  So we've talked about unconscious bias in the broader context of the relationship between parents and child in a child protection setting. 


MS EASTMAN:  I'm asking you about the extent to which unconscious bias with respect to children with disability and in particular intellectual disability arises.

DR CRAWFORD:  The thing about bias is it's very individual so to be able to say to what level across the agency, I'm not sure that I could describe that, but it's certainly something we are conscious of for individual practitioners. 

MS EASTMAN:  Could I ask you to have a look at your paragraph 17. 


MS EASTMAN:  And just quickly read that to yourself. 


MS EASTMAN:  Have you had a chance to read that? 


MS EASTMAN:  Do you accept, reflecting on paragraph 17, that what you've said in that paragraph is laden with unconscious bias and assumptions about young people who you've described as non-verbal? 

DR CRAWFORD:  What I do know about the case is that we went   

MS EASTMAN:  No. No. I'm not asking you about the case. I'm asking you about what you've written here and I'm asking you about whether or not you agree it is laden with unconscious bias about a young person with disability who you describe as non-verbal. 

DR CRAWFORD:  No, I don't think it is laden. 

MS EASTMAN:  Do you accept that what you've said in paragraph 17 with respect to excusing, if I can put that to you, the lack of communication with Kaleb and Jonathon on the basis that they were non-verbal is reflective of an unconscious bias in the way in which children who are non-verbal can express their wishes, their concerns or their grievances? 


MS McMILLAN:  I object to the question.  That's about three questions in one.  So if my learned friend could break it up.

MS EASTMAN:  She answered -- 

DR CRAWFORD:  What I say in   what I say in   yes. 

MS EASTMAN:     that would you agree, looking at the totality of the agreed facts and to the extent you're familiar with the underlying documents, that there is no evidence of a Child Safety Officer, first, developing a plan to communicate with Kaleb or Jonathon. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And, secondly, any evidence recording any attempt to engage with Kaleb or Jonathon privately away from their father to ask them about what was happening in their life. Would you agree with that? 

DR CRAWFORD:  I would agree. 

MS EASTMAN:  And do you agree that the absence of any plan or any attempt to talk to these two young people over the course of the 20 years is a deficiency in the way in which the Child Safety officers engaged with this family? 

DR CRAWFORD:  From my reading, there were attempts to engage with the young people. They were certainly visited, both at home and at school. So, there was engagement with them. There were observations of them, and there was engagement with their teachers and other workers who provided support with them in order to gather information about their safety and wellbeing. 

MS EASTMAN:  Well, it's one thing to watch them, observe them, but it's another thing to have direct communication, and communication in a manner that's appropriate to their level of language, their level of comprehension and their level of engagement. 


MS EASTMAN:  Do you agree with me, reflecting on all material, that throughout Child Safety's engagement with this family is that the bias was always towards the information provided by the father or other people such as in the Department of Education, teachers who worked with the two young people? 

DR CRAWFORD:  There was definitely a focus to the information, and our workers must look at the impacts for the children, so those observations, those visits, the coordination of supports all contribute to the assessment. 

MS EASTMAN:  And what do you say should have happened if there should have been communication with the two young people?  What should have happened in terms of communication with them? 

DR CRAWFORD:  We should have sought information, particularly from the school, who were very skilled in working with the children, about what communication was possible with them, what methods were possible to use. So, that should have   

MS EASTMAN:  And why didn't that happen? 

DR CRAWFORD:  I don't know. I don't know. 

MS EASTMAN:  I want to bring you now to paragraph 9 of your statement. 


MS EASTMAN:  And you tell the Royal Commission that the department's involvement with the family spans almost a 20 year period, and during that time the department's practice was guided by the Child Protection Act. 

DR CRAWFORD:  That's right. 

MS EASTMAN:  So the Child Protection Act sets out the department's functions, powers, and it also describes and defines particular terms that set, in effect, the parameters of what the department can do. As you've said in the statement:

    ‘Fundamental to the departmental decision making is the concept of a child who is in need of protection, and that is defined as a child who has ...’ 

And you've got three elements of this:

    ‘... suffered significant harm.’

So, that focuses on an event or something that has occurred; is that right? 



    ‘.. is suffering significant harm.’

So, that brings it to present circumstances:

    ‘... or is at an unacceptable risk of suffering significant harm.’

And that has a predictive future element to it. 

DR CRAWFORD:  Yes. We need to look at the probability of future harm in that regard. 

MS EASTMAN:  That's the first element. So, harm is an overarching concept, and I'll come to the definition in a moment. The second element is:

    ‘... does not have a parent able and willing to protect from harm.’

So, this concept very much links to the identification of harm. You agree with that? 


MS EASTMAN:  It inherently requires the parent to understand what the harm is, for an assessment to be made as to whether the parent is able and willing. 

DR CRAWFORD:  That's right.

MS EASTMAN:  So, there are two elements to what needs to be assessed? 

DR CRAWFORD:  That's right. 

MS EASTMAN:  You've said in paragraph 9 of your statement that:

    ‘Harm to the child is defined in section 9(1) of the Child Protection Act.’

And you've described it as:

    ‘.. any detriment effect of a significant nature on their physical, psychological or emotional wellbeing.’ 

DR CRAWFORD:  That's right. 

MS EASTMAN:  And you've also referred to section 9(2). Now, I think we have section 9 of the CPA, which I've brought up on the screen. Commissioners, you can see that. So, this is taken from the current version of the CPA. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  When you have a look at that definition of harm, you've extracted in your paragraph 9 the language from section 9(1) and you've also focused on section 9(2), which is it doesn't matter how the harm's caused. What you haven't included in your section 9 is the additional elements in 9(3) about the way in which harm can be caused. That includes:

    ‘... physical, psychological, emotional abuse or neglect.’

So, the language of ‘neglect’ is an element of harm. And harm can be caused in 9(4):

    ‘... by a single act, omission or circumstance.’

But importantly, in (4)(b):

    ‘... a series or combination of acts, omissions or circumstances.’

So, ‘omissions’ is a relevant concept to take into account. Looking at that definition, if we wanted   if we're being lawyers, we seek out other definitions.  ‘Neglect’ is not defined anywhere in the Act. 


MS EASTMAN:  You in your statement have included some articles about the concept of cumulative neglect. So, if I can take you to paragraph 29 of your statement. 

DR CRAWFORD:  Yes. Ms Eastman, do you mind if I just clarify why I made the distinction between harm and didn't include all of the elements of the section? 

MS EASTMAN:  Well, if you can listen to my questions, we may get to that. 


MS EASTMAN:  But if you feel that you need, after the questions I'm about to ask you, the opportunity to do that, let me know.

DR CRAWFORD:  Thank you. And I'm sorry, which paragraph? 

MS EASTMAN:  Paragraph 29. The document's not paginated so I've just had to go by paragraph. 

DR CRAWFORD:  Yes, thank you. 

MS EASTMAN:  So, paragraph 29, you acknowledge that there was a considerable amount of departmental contact with the family, and it is evident from this contact there were patterns of events and circumstances which indicated a cumulative impact on the safety and the wellbeing of young people. 


MS EASTMAN:  And you say the assessment of cumulative harm is well recognised as a challenge for child protection practitioners. 


MS EASTMAN:  Now, the article that you've referred to, which I think you've got with you now. 


MS EASTMAN:  You have quoted an extract from page 7 of the Bryce and others article. You see that? 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And I assume that you read this article carefully before deciding to include it in your statement and also to extract that passage there; is that right? 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  This article reflects some research that was undertaken to look at what the authors describe as a concept of cumulative harm, which the authors say happens to be a largely Australian term. But you would agree, reading through this article and the way in which ‘cumulative harm’ is described, that, in effect, it is neglect and it is neglect over a period of time that could also be characterised as systemic neglect. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  You agree with that? 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And as you read through the article and the extracts of evidence that are included, that the neglect that arises on a cumulative basis is a mixture of particular incidents, but it also includes omission and it also includes the cumulative effect of a series of acts and a series of omissions. 


MS EASTMAN:  And it also requires an understanding of the context in which the child's welfare or safety is at risk. 


MS EASTMAN:  That context is not just looking at the particular incident that occurs, but the context is to look at the safe   safety and protective factors around the child   


MS EASTMAN:   with the immediate family and then branching out to the community and then branching out to the government institutions that may have the power to intervene or react. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And one of the issues raised in this article is the importance of understanding the family structure. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And particularly the issues around how parents may struggle. For example, if parents have intergenerational experience of trauma, if parents have a hostility to engagement with government or other agencies, and if parents are reluctant to accept help and assistance and therefore that can have the impact of fostering, as they say, fear and hyper vigilance. So, would you agree that when you have described and used the expression ‘cumulative harm’ that, in effect, you are referring to a context of neglect that's captured by sub section (4) in section 9 of the Child Protection Act?  We can bring that back up if you need it. 


MS EASTMAN:  And to the extent that in paragraph 29 you refer to the:

    ‘... cumulative impact on Kaleb and Jonathon ...’

Can we take by what you say in paragraph 29 as an admission that each of these two young men experienced neglect and, indeed, cumulative harm as a result of that neglect over their life course? 

DR CRAWFORD:  Yes. And our investigation and assessment outcomes reveal that.  We had substantiated outcome. So, that was recognised by departmental workers. 

MS EASTMAN:  And in terms of responding to neglect, if we look at the totality of the evidence, for the most part, the responses were to the single act, omission or circumstance that may have been reported to Child Safety? 

DR CRAWFORD:  Yes. And the subsequent assessment information. So, the information that was gathered through the assessment process. 

MS EASTMAN:  But it's difficult, would you agree, looking at the totality of the material, to see when and how the department consciously   and without unconscious bias, consciously did an assessment of whether the patterns of behaviours, the patterns of omissions and the patterns of interactions within the immediate family and the broader family were very significant markers of a very significant risk of neglect to both Kaleb and Jonathon. 

DR CRAWFORD:  I hear what you're saying, Ms Eastman, and that is why at times we substantiated ‘at risk’. So, there was a recognition of the history of the patterns of the cumulative nature for the boys, which was why we had outcomes that said – ‘risk’ and why we intervened with them through a number of different mechanisms, such as the child protection order, such as intervention with parental agreement, and there were a couple of those. 

MS EASTMAN:  But you agree with me that those interventions were primarily directed to a particular acute circumstance at the time, and that none of the interventions proactively addressed the neglect? 

DR CRAWFORD:  I wouldn't agree with that. I think that very much the interventions were focused on neglect, particularly the neglect as seen through the household environment, the boys' hygiene, the boys' diet. I think there were particular focus   that was a particular focus of the intervention and of the referrals that were made as well. 

MS EASTMAN:  Let me give you one example. This is in the agreed facts at paragraph 286 to 288, and accepting for the relevant timeframe it is Jonathon, who is still a child. On 10 February 2019, Child Safety officers attended the home unannounced and did a safety assessment in response to a notification that had been received on 9 February. That notification, if it assists, is set out at paragraph 284, and it's a health professional who had notified the Department of Child Safety of concerns expressed to them by a community member. So, you've got a community member raising it with a health professional, who in turn has raised it with   


MS EASTMAN:    you. The health professional would have been a mandatory reporter by then. 


MS EASTMAN:  So the response to that notification is for the Child Safety officers to do an unannounced visit or attendance at the home. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And the facts record that there was an interview with the father and an observation with Kaleb and Jonathon. The records record this:

    ‘During the visit, Kaleb was not in the house and had gone outside. At the end of the visit, as the Child Safety officers were leaving the home, Kaleb was observed sitting in the overgrown grass at the front yard eating a large raw dog bone, which the dog was observed to have been eating at the time of Child Safety's arrival.’

Now, accepting at this stage that Kaleb was by then, I think, 18 and accepting that this is the circumstances in which he lived, and that his younger brother lived in those same circumstances, would not an observation of a young person eating dog   or chewing on the dog bones after the dogs had had the bones, would have been something that should have alerted the department to a risk in the immediate term but may also have required the department to do some more detailed investigation as to how and why circumstances like that could have ever occurred? 


MS EASTMAN:  Do you agree with that? 

DR CRAWFORD:  Yes. And I also read that material. It's very distressing. I could see from the case worker's own notes that they were very distressed about the situation for both the boys, as you say, one being an adult at that time, recommending strongly a multi agency response to the needs of both children, and some follow up that then occurred. So, that was not a one off visit. That was one visit as part of that investigation and assessment process. 

MS EASTMAN:  But at 290 of the agreed facts, the department considered that it was not legally mandated to intervene in relation to Kaleb and that there needed to be ongoing discussions with the NDIS to ensure Kaleb received the level of care he required. That rather suggests that, in the context of these two young people, that once they hit the magic age of 18, then Child Safety is out of their life; is that right? 

DR CRAWFORD:  I wouldn't   well, we don't have a legal framework to intervene with adults. I think what this demonstrates is that there was concern for him, concern for his safety and wellbeing, and a recognition that there needed to be follow up with adult services. So, they certainly didn't think, oh well, this is an adult, we're not going to intervene. They wanted to ensure there was follow up by the appropriate agencies. Our Act doesn't allow us to intervene with adults. 

MS EASTMAN:  So what other agencies were available, then, to intervene with respect to adults? Because clearly a concern is one thing but action is something else. You'd agree with that? 

DR CRAWFORD:  Yes, absolutely. Yes. So, the NDIS was available in that location at that time. 

MS EASTMAN:  You know the NDIS is not a service provider itself, is it? 

DR CRAWFORD:  No, but it funds particular agencies which can be contacted for support. 

MS EASTMAN:  And you know there's no requirement to participate in the NDIS? 


MS EASTMAN:  And did your department make any inquiries of the NDIS as to whether or not Kaleb had a service provider or was providing services in the home in 2019? 

DR CRAWFORD:  I would need to take that on notice. As I   as far as I am aware, there was an NDIS package for him at that time, but I would need to take that on notice. 

MS EASTMAN:  You didn't hear the evidence yesterday? 


MS EASTMAN:  That   with respect to his package of over $102,000, that in the first year of that package, the spend was $361 on transport and continence products. 

DR CRAWFORD:  That is shocking. 

MS EASTMAN:  Nothing else. 

DR CRAWFORD:  That's shocking. 

MS EASTMAN:  If Child Safety was aware of that information, what could Child Safety have done in those circumstances, either by way of referral to the police or elsewhere? 

DR CRAWFORD:  I'm not sure that a police referral would have been the option, but there would have been the follow up with the support coordinator and the NDIS   the agency who was provider much of the support under the agreed package. 

MS EASTMAN:  But it's not part of the NDIS's functions to address a circumstance like that, is it? 

DR CRAWFORD:  We have a number of inter jurisdictional governance bodies and contacts within the NDIA which we can escalate matters to. So, that's an option to us if we're trying to navigate what services are in place for a particular child or young person. 

MS EASTMAN:  Right. I want to take you back to paragraph 29 and in terms of the quotes that you make about   from the Bryce article, and you talk about cumulative harm   this is towards the end of the page   resulting from neglect associated with poverty, substance abuse, poor mental health and inadequate housing. Would you agree, in effect, that describes this family? 


MS EASTMAN:  It is a family experiencing poverty. 


MS EASTMAN:  Substance abuse, poor mental health and inadequate housing? 

DR CRAWFORD:  Well, it was a Department of Housing Commission house so they did have some housing stability, and it was that family only in that house. 

MS EASTMAN:  You've seen the photos of the conditions of the house, haven't you? 

DR CRAWFORD:  Yes, I have. 

MS EASTMAN:  You're not suggesting to the Royal Commission that that was adequate housing based on those photos?

DR CRAWFORD:  No, I'm not suggesting that.  What I'm saying is   

MS EASTMAN:  You're saying they had a house. 

DR CRAWFORD:  Yes, I'm saying they had access to a Department of Housing home. 

MS EASTMAN:  But in terms of living conditions, you'd agree that was not adequate. 

DR CRAWFORD:  That was not adequate. 

MS EASTMAN:  I think you've said in your statement that there were 23 occasions where particular matters through notifications were brought to the department. Would you agree that a review of those 23 notifications provided the department with ample evidence of the risk factors to the   to Kaleb and Jonathon with respect to harm as described in the Child Protection Act? 

DR CRAWFORD:  Yes, and there were matters that, following investigation and assessment, were substantiated and there was acts of intervention provided. 

MS EASTMAN:  And in terms of that element of having a parent who was able and willing to address the harm, would you agree that the department had ample knowledge about Paul Barrett's behaviours, the nature of his engagement with government authorities that would have squarely put the Department of Child Safety on notice that he was unwilling and unable to address the harm to either of his sons? 

DR CRAWFORD:  It is why we took a child protection order in relation to the older child, and, after some negotiation with him, he certainly expressed a strong commitment to improving the situation, and that's when interventions like intervention with parental agreement with opened, but acknowledging that these were children in need of protection and in need of intervention to improve their circumstances. 

MS EASTMAN:  What would have needed to have occurred for each or both of these two children, when they were children, to be permanently removed from Paul Barrett? What would it have taken? 

DR CRAWFORD:  We would have needed to have gone before a magistrate and identified that they were children in need of protection. As you will see through the principles of our Act, we do have an obligation to work with families and to support them, and even when we remove them, there is an obligation for us to work to increase safety and to, where possible, return them home. I think a magistrate would have said to us that you need to be intervening with him to improve safety. 

MS EASTMAN:  But you don't   

DR CRAWFORD:  But that was not   

MS EASTMAN:  You don't know that. You're speculating on that? 

DR CRAWFORD:  I'm speculating, absolutely. 

MS EASTMAN:  But you never at any stage in   except for that first two years, took that step of approaching a magistrate to at least determine whether this was at a sufficiently high level of seriousness in terms of the harm occasioned to these young people  


MS EASTMAN:    that they should be removed? 

DR CRAWFORD:  We did not test that. What is of interest is that in 2010, after a period of intervention with parental agreement, there was noted improvement in the circumstances, confirmed by the school, who were seeing the children very regularly, and then no notifications received for a four year period which may say something about   notified behaviour and may say something about the father's ability to maintain change. 

MS EASTMAN:  But isn't that the very point that we started with, is if the model is one of reaction and it requires a notification   


MS EASTMAN:    then the absence of hearing something does not mean everything's fine, does it? 

DR CRAWFORD:  It does not equal safety. 

MS EASTMAN:  That's the point of the unconscious, bias, is it not? 

DR CRAWFORD:  Yes. And it is why we had at times referred the family to Family and Child Connect so that they were linked to a secondary provider, which as I explained earlier is a family support option to try and divert from the tertiary child protection system. 

MS EASTMAN:  Just in the time available, I want to turn to just a couple of questions about your response to the SCAN meetings. 


MS EASTMAN:  So, as I said, your statement's not paginated and then the paragraph numbering changes. So, if I can take you to paragraphs 32 and then the next paragraph on the next page is 1. 

DR CRAWFORD:  Yes. Apologies for that. 

MS EASTMAN:  So I've got to work with the page that we're on that starts with number 1. 


MS EASTMAN:  And you've set out the circumstances of when and how a SCAN meeting occurs. 


MS EASTMAN:  It's the case, isn't it, that Child Safety is the key agency or the leader? 

DR CRAWFORD:  Yes. We're the lead agency for SCAN. 

MS EASTMAN:  And that the purpose of a SCAN meeting is to ensure that there is a critical and comprehensive assessment of the risk of harm to a child? 

DR CRAWFORD:  What it allows for is a coordination of information from a number of key agencies. So, those key agencies include the Queensland Police Service, Department of Education, Department of Health, our agency and, as a result of a more recent coronial inquiry, we are now able to invite other critical partners like family support agencies. 

MS EASTMAN:  And you would expect that all of the members of SCAN team would be very well aware of the risk of unconscious bias? 

DR CRAWFORD:  I would expect so. 

MS EASTMAN:  And are the members of the SCAN team people who have particular training or experience with children and young people with disability? 

DR CRAWFORD:  I would suggest so but not necessarily. 

MS EASTMAN:  Does the SCAN meeting, to the extent it ever is dealing with a circumstance of a young   a child or young people with disability, bring in a disability specialist into those meetings? 

DR CRAWFORD:  Not that I'm aware of. I think it would be a good outcome. I also think mental health experts would be good from time to time as well. 

MS EASTMAN:  And at any of the SCAN meetings that you've referred to in your statement, was there ever any participation by a member who had particular expertise for children and young people with intellectual disability? 

DR CRAWFORD:  Not that I'm aware of. 

MS EASTMAN:  Do you agree that the absence of that expertise in a meeting with the purpose that it has of SCAN was a deficiency? 

DR CRAWFORD:  I think it would have   it would have brought great value if that was available. 

MS EASTMAN:  If I ask you to reflect on, I think, the final SCAN meeting before the father's death, it's agreed fact 272. This is a SCAN meeting of 14 January 2019.  The Child Safety Officer is recorded as thinking Paul Barrett was doing:

    ‘... his absolute best and he loved Kaleb and Jonathon.’

Would you agree with me that the father doing his absolute best and/or a Child Safety Officer reflecting the officer's view that the father loved his children is not the test required by section 9 of the Act? 

DR CRAWFORD:  I would agree. 

MS EASTMAN:  And do you agree that, in some senses, encapsulated in this one sentence is really the essence of why, may I put to you, Child Safety let both Kaleb and Jonathon down, and that is because throughout the engagement with this family, excuses continued to be made because Paul Barrett was dealing with difficult children, dealing with kids with disability, doing his absolute best and this misconceived view that he loved his children. 

MS McMILLAN:  I object to that question. It's a whole lot of propositions that the witness hasn't necessarily agreed with. 

MS EASTMAN:  Well, she has the opportunity to answer those propositions. 

DR CRAWFORD:  Ms Eastman, if we had unsubstantiated every outcome, then I think you would have a point. But we did not. We substantiated it, and we substantiated risk, and we opened intervention, and we made referrals, because we did understand the impacts for the children. We did understand that this father needed to increase his functioning and, in turn, improve safety for children. 

MS EASTMAN:  But that never happened, did it? 

DR CRAWFORD:  Well, it did from time to time. Yes, it did. 

MS EASTMAN:  When you say it happened from time to time, you say that because there was an absence of notifications telling you otherwise. 

DR CRAWFORD:  No. No. No. I say that because there were open periods of intervention with him and noted improvements over time. So, no, I agree with you that the absence of reports does not equal safety, but what I see is the active intervention that occurred with this family from the department. 

MS EASTMAN:  Do you accept that the answer that you've just given diminishes an understanding of cumulative harm and the nature of systemic neglect? 

DR CRAWFORD:  No, I don't think it diminishes. 

MS EASTMAN:  You don't accept   

DR CRAWFORD:  Because as I said before, we were substantiating risk. 

MS EASTMAN:  Right. I want to ask you about paragraph 18, which is the Disability Practice Kit.


MS EASTMAN:  And you've given us a date there of 2000   sorry, 2020, my apologies. When in 2020 was this published? 

DR CRAWFORD:  It would have been toward the end of 2020. So, we brought a new Child Safety Practice Manual in in December 2019, and then we built those practice kits over that time. It was at a time when we were trying to build our internal capability regarding an understanding of disability and how we should assess and intervene and it was through a team that sits within the Office of the Chief Practitioner. 

MS EASTMAN:  Was thee practice kit co designed with people with disability? 

DR CRAWFORD:  No, it was not. 

MS EASTMAN:  Why not? 

DR CRAWFORD:  It should have been. 

MS EASTMAN:  Have any steps been taken to review the practice kit to work with people with disability and, in particular, children and young people with disability? 

DR CRAWFORD:  We have gone to some focus groups with advocacy services and included parents with a disability in that formulation, but not children, as I understand it. 

MS EASTMAN:  Have you approached any of the peak disability organisations like CYDA, Children and Young People With Disability? 

DR CRAWFORD:  I will take that on notice and   

MS EASTMAN:  In fact, you don't know. 

DR CRAWFORD:  I don't know but I'll double check. 

MS EASTMAN:  Would you accept that if you want to have an effective practice kit that can be a tool to be used by people on the ground that it needs to have the input of people with disability? 

DR CRAWFORD:  I absolutely agree. 

MS EASTMAN:  Is the practice kit currently required to be used by the Department of Education? 

DR CRAWFORD:  No, not Department of Education, no. 

MS EASTMAN:  Is it required to be used by the Department of Housing? 

DR CRAWFORD:  No, this is an internal practice kit for our department. 

MS EASTMAN:  Is it used   do you know if it's used by the police. 


MS EASTMAN:  And do you know if it's used by Health? 


MS EASTMAN:  Has your department undertaken any training on the risks to children and young people with disability with the Department of Education? 

DR CRAWFORD:  As a joint training? 

MS EASTMAN:  Joint training or you've delivered training? 


MS EASTMAN:  Have you delivered training to the Department of Housing? 


MS EASTMAN:  Have you delivered any training to police? 

DR CRAWFORD:  Not in relation to disability.  In relation to interviewing children, yes, but not in relation to   not a specific disability training program. 

MS EASTMAN:  So police have done some training with the department on interviewing children. 

DR CRAWFORD:  Yes, and   

MS EASTMAN:  But not with children with disabilities. 

DR CRAWFORD:  That's right. 

MS EASTMAN:  Has there been any training with the Department of Health in the disability kit? 


MS EASTMAN:  Are you aware of whether or not any of those three departments and agencies have used the Child Safety resources? Are you able to track whether they've used them or not? 

DR CRAWFORD:  No, I can't track use, no. 

MS EASTMAN:  But they're publicly available? 

DR CRAWFORD:  They are. 

MS EASTMAN:  One matter which we didn't ask you in the indicative findings   sorry, just for completeness, I want to ask you about the involvement, if any, with the Queensland Family and Child Commission review. You're aware of the review? 

DR CRAWFORD:  For this particular case, yes. 

MS EASTMAN:  And was your agency involved in that review? 

DR CRAWFORD:  We   information was requested of us and we supplied what was requested. 

MS EASTMAN:  Did that include information of a systemic or general nature about policies and practices? 

DR CRAWFORD:  Yes, that's right. 

MS EASTMAN:  Did it include all of the records that the department held in relation to the 23 or so notifications and various interactions? 


MS EASTMAN:  Is there a reason why that wasn't provided to the QFCC? 

DR CRAWFORD:  At the time of the review, the older young person was an adult, so the legislation would not have allowed for that, and actually I'm not sure that the legislation allows for us to share information about the individual other young person.  And I have read the letter that QFCC sent to us in recent days, and that was not requested. 

MS EASTMAN:  And you   did your department receive a copy of a report by the Attorney General? 


MS EASTMAN:  And in terms of that report, what consideration was given to the contents of that report? I ask you that because yesterday there was some evidence that Ms McMillan drew to the witness's attention   Commissioners, it's at Annexure U of Mr Twyford's statement   where the Attorney says ‘I'm providing this to the relevant Ministers’ and we assume that it also went to the relevant departments. 

DR CRAWFORD:  Yes, absolutely. 

MS EASTMAN:  So were you required by the Attorney General or your Minister to do anything in response to the review report? 

DR CRAWFORD:  We certainly reviewed it. 

MS EASTMAN:  What does that mean? 

DR CRAWFORD:  We looked at the findings. So, from memory, there were three findings. So, it was very COVID focused because of the period of disengagement from school during the COVID closures. So, we considered that finding. We had actually worked very actively with Education   

MS EASTMAN:  I'm just asking you about the review report. 

COMMISSIONER RYAN:  Can I just   Senior Counsel asked you were you required to do anything about it, and you didn't quite answer that question. Were you required. You said that you did, but were you asked to do it? 

DR CRAWFORD:  I don't think there were recommendations for us to follow up on.  So, if there were recommendations for the department to follow up on we would do so, but as I recall they were findings which we reviewed to ensure that anything significant    

COMMISSIONER RYAN:  So, is the answer to that question, no, you were not asked to do anything? 

DR CRAWFORD:  I will take that on notice. 


DR CRAWFORD:  But we   we're very respectful of the reports that are handed down by QFCC. 

MS EASTMAN:  Well, did anything happen? 

DR CRAWFORD:  As a result? Well, we were already doing things that   

MS EASTMAN:  I'm not asking what you were doing before but what action or what happened, if any, in response to the review report?

DR CRAWFORD:  I don't think there were any actions in response to the review itself. 

MS EASTMAN:  Were you required to have any consultation with any other departments? 


MS EASTMAN:  In relation to the review report? 


MS EASTMAN:  Were you required to address any systemic issues? 


MS EASTMAN:  Did anything happen in response to this report? 


MS EASTMAN:  That you're aware of? 

DR CRAWFORD:  No, but I'll take it on notice. I'll come back to you. 

MS EASTMAN:  After 27 May, Jonathon was still a child. 

DR CRAWFORD:  Mm hmm. 

MS EASTMAN:  And what were the Child Safety obligations when Child Safety became aware that Paul Barrett had passed away? 

DR CRAWFORD:  So, we assessed whether he was a child in need of protection and a child protection order was sought for him. 

MS EASTMAN:  So, he was a child that needed protection? 

DR CRAWFORD:  He was. 

MS EASTMAN:  And an order was sought? 


MS EASTMAN:  And you were aware that a guardian was appointed? 


MS EASTMAN:  I just want to put these final two things to you. Would you accept, having looked at the agreed facts, the underlying documents and in the course of preparing a statement for this case study, that Child Safety could have taken action to prevent the violence, abuse, neglect and the deprivation of rights for both Kaleb and Jonathon? 

DR CRAWFORD:  I would suggest the department did take action. 

MS EASTMAN:  I'm asking you if they could have taken action. 

DR CRAWFORD:  Well, they did take action. 

MS EASTMAN:  Well, you accept, do you not, that each of Kaleb and Jonathon experienced violence, abuse, neglect and a deprivation of their rights during the time they were in their father's care? 


MS EASTMAN:  You accept that? 

DR CRAWFORD:  Yes, that was   they were substantiated outcomes recorded by the department. 

MS EASTMAN:  It didn't need a substantiated outcome. It simply needed observation to know and understand that each of those young men experienced violence, abuse, neglect and a deprivation of their rights. Do you agree? 

DR CRAWFORD:  And it is conveyed in our assessments.

MS EASTMAN:  Do you accept that the violence, abuse, neglect and deprivation of their rights was preventable? 

DR CRAWFORD:  There were attempts to prevent the abuse by supporting the father. 

MS EASTMAN:  But they were preventable, weren't they? There's nothing inherent in these particular children because they had disabilities that they should be subject   

DR CRAWFORD:  Of course not. 

MS EASTMAN:    or expect to be subject to   

DR CRAWFORD:  Of course not. 

MS EASTMAN:    the level of violence, abuse, neglect and deprivation of their rights.  You agree with that? 

DR CRAWFORD:  When you say violence, there was not a pattern of physical abuse of these children. 


MS EASTMAN:  Are you sure about that?  Are you sure about that? 

DR CRAWFORD:  There was one allegation of a bruise to the older child's eye. 

MS EASTMAN:  Have you read all the agreed facts?

DR CRAWFORD:  Yes, I have. 

MS EASTMAN:  Have you read the circumstances of a report made about Paul Barrett's physical treatment of the children at a camp ground? Kicking, hitting, slapping? 

DR CRAWFORD:  No, I did not read that. So, I understood that police had intervened at a camping ground and that they found there was no harm to the children. 

MS EASTMAN:  Do you accept that being locked in your room for a weekend or over the school holidays where you can't get out of your room because there was no handle   you don't accept that's violence? 

DR CRAWFORD:  I wouldn't regard it as violence, but it was not  

MS EASTMAN:  What do you regard as violence, then?


MS EASTMAN:  What's required of violence? 

DR CRAWFORD:  Well, typically violence is a violent act towards another resulting in a physical injury. So, I'm not suggesting   

MS EASTMAN:  You don't accept coercive control is violence? 

DR CRAWFORD:  But I'm not suggesting that these circumstances were adequate for these children. I don't    please. 

MS EASTMAN:  You are not saying to this Royal Commission that these children did not experience violence, are you? 

DR CRAWFORD:  What I'm saying is there was not a pattern of physical abuse of these children in our records.  In our records. 

MS EASTMAN:  But isn't one incident of violence enough? 

DR CRAWFORD:  Yes, of course, and we   and people should respond to that. 

MS EASTMAN:  Right. So, I'll come back to my question which is do you accept that the violence, abuse, neglect and the deprivation of Kaleb and Jonathon's rights was preventable? 

DR CRAWFORD:  Yes, and we worked to prevent it. 

MS EASTMAN:  Do you accept that Child Safety was the lead agency in addressing prevention of the violence, abuse, neglect and deprivation? 

DR CRAWFORD:  Yes, while they were children, absolutely. 

MS EASTMAN:  Do you accept and agree that Child Safety could have done more to prevent the violence, abuse, neglect and deprivation of rights?  I accept what you say earlier, you did things, but you could have done more? 

DR CRAWFORD:  We certainly substantiated. We certainly had active follow up. We opened intervention with parental agreement. We identified that these were children in need of protection. 

MS EASTMAN:  You could have done more. 

DR CRAWFORD:  And we intervened. 

MS EASTMAN:  You could have done more. 

DR CRAWFORD:  Could have done more. 

MS EASTMAN:  Do you accept that? 

DR CRAWFORD:  Yes. Right. 

MS EASTMAN:  And do you accept that you should have done more? 


MS EASTMAN:  Thank you. Those are my questions. 

COMMISSIONER McEWIN:  Thank you, Ms Eastman. Dr Crawford, I will ask my colleagues whether they have any questions for you. Commissioner Mason? 

COMMISSIONER MASON:  Thank you, Chair. Dr Crawford, there's a saying that I have come to know since being appointed as a Commissioner in this Royal Commission. That's the phrase, ‘Nothing about us without us.’ Are you aware of that phrase? 


COMMISSIONER MASON:  And what does that phrase mean to you? 

DR CRAWFORD:  Well, it means a number of things, but it's about involving children, about involving families, about involving communities in decision making and   in assessments and decision making. 

COMMISSIONER MASON:  I don't think that's what that means because the key element that's missing with your response is disability. So, it comes from the work of the advocacy from the disability community in relation to the Convention on the Rights of Persons with Disability. And it's about ensuring that in decisions that are made regarding a person with disability that it's for, with and through them. And so I just want to go back. Ms Eastman was asking you questions about SCAN, and there were a number of SCAN meetings from the year 2000 right up to 2019. And you've responded to Ms Eastman's question that there wasn't anyone in those meetings who could provide   who was a subject matter expert in relation to intellectual disability. I just wanted just to make sure, be clarified, was there anyone in those meetings who was a disability advocate or representing disability services? 

DR CRAWFORD:  No, Commissioner, there wasn't. 

COMMISSIONER MASON:  So that phrase, ‘Nothing about us without us’ in my mind, just listening to the evidence this morning, is not acculturated in the department? As in it's embedded in the policies, procedures and practices of the department. So, here are two young men and that, in 2020, one was still a child, and long history of understanding the circumstances in the family, but there wasn't at any time a mindfulness to connect the community   the disability community with these young boys? 

DR CRAWFORD:  Yes, I can see that. 

COMMISSIONER MASON:  Is that something the department could take on notice to look at? I know that you may not be the right person to answer this question, and I may ask this question of other witnesses today around that particular phrase, because as a First Nations person, self determination is acculturated in departments, in jurisdictions for sure, and at Commonwealth level. 


COMMISSIONER MASON:  But I think that's a really critical question, when the best approaches and the use of finite resources and the urgency of intervention is needed, particularly with children with disabilities in very concerning circumstances Ms Eastman has talked about. So, in those SCAN meetings, you responded to Ms Eastman in that your agency was the lead agency. Were there Commonwealth agencies in those meetings as well? Was it only State? 

DR CRAWFORD:  Yes, that's right, only State. 

COMMISSIONER MASON:  And is there a limitation for  Commonwealth agents to attend   I'll call these integrated response meetings, these SCAN meetings. Was there a limitation? 

DR CRAWFORD:  SCAN was actually enshrined in legislation in 2005, and the way the legislation is currently written, it doesn't include Commonwealth agencies. That doesn't mean that we can't convene meetings with Commonwealth agencies outside or as on a needs basis. So, we also have stakeholder meetings and practice panels, those sorts of forums, that bring information together. 

COMMISSIONER MASON:  What has struck me over the last couple of days is agencies, whether they be Commonwealth or State, in a response to material provided by Counsel Assisting, the representative will say, ‘Oh, we didn't know about that. We weren't aware of that. If we knew, we would have done X’. 


COMMISSIONER MASON:  It seems to me that it's not enough to just have some of the representatives in the room in relation to serious risk of harm, but there needs to be everyone who has a line of sight, because not all pieces of the puzzle are actually sitting at that meeting. So   

DR CRAWFORD:  Yes, I can see that, Commissioner, and it is why in more recent times we have been able to involve family support agency staff as well. So, I think there's certainly some scope to review who is at the SCAN team table and who is sharing information.  So thank you. 

COMMISSIONER MASON:  Thank you, Commissioner. 

COMMISSIONER McEWIN:  Commissioner Ryan. 

COMMISSIONER RYAN:  Thanks, Mr Chair. Ms Crawford, I'm still trying to comprehend your answer to the question that these boys did not experience violence. Have you heard the evidence that we were told these boys showered night after night in cold water because there was no gas in the house? Where they slept night after night in a room, locked from the outside, with no blanket wearing nothing more than a nappy, night after night, cold and hot, in an unfurnished room where they had no access to the toilet and they were literally found in the morning slipping around in their own faeces? And then   and   and they were being fed raw meat, but they couldn't even open the packet. Are you seriously telling the Royal Commission that those conditions, which sound like torture to me, don't represent that these boys did not experience violence? 

DR CRAWFORD:  I acknowledge that, and I'm sorry for the misunderstanding, Commissioner. I was referring to physical abuse at the hands of their father, but I'm sorry that there's been a miscommunication. 

COMMISSIONER RYAN:  Well, you'd agree with us that violence has a slightly wider definition than physical violence? 

DR CRAWFORD:  Indeed. I would agree with you. 

COMMISSIONER RYAN:  Ms Crawford, one of the things that occurs to me about your statement is there was barely any sort of evidence of reflection in it, that having   you've read the statement of facts that I have read in the last week? 

DR CRAWFORD:  I have. 

COMMISSIONER RYAN:  Where there appears to be visits   20 visits from your department or notifications, multiple visits, in which there wasn't   for example, the incident you were talking about earlier with Senior Counsel where one of the boys were was seen gnawing on a dog bone. One of the other observations made by your staff was that there was one room with an inflatable mattress and several piles of faeces; one mattress outside with brown, wet stains   well, I don't think you need any imagination to understand what that was   and that the home smelt of faeces. And yet later on, people go back to the office and they make a conclusion that there's no evidence of harm. There's a certain common sense value to this that the regular member of the public would say   I must say,  it would to me   that if those boys are not removed from that house, something seriously needs to happen to improve the circumstances in which they're living, doesn't it? 

DR CRAWFORD:  Yes, and I think that was the approach that the department took in a majority of cases. 

COMMISSIONER RYAN:  So, I'm talking about your statement.  There doesn't appear to be any reflection that   there's an acknowledgement that there was an interaction and there seems to be excuse after excuse. The kids were nonverbal, you know, we didn't see that, there was no one critical incident. There's not an evidence even on reflection of your part that our department   if this could happen on our watch, we need to do something different and here are some recommendations, perhaps arising from the report done by the Family Commission where we need to   do you agree that there are no recommendations or suggestions for improvement in your statement?

DR CRAWFORD:  Yes, I agree that that   I did not think that that was the purpose of the statement for the Royal Commission. It is part of my role, Commissioner, to review matters and to make recommendations and actions, I do that actively as Chief Practitioner. 

COMMISSIONER RYAN:  Well, you've had some opportunities, I think, in various questions to answer questions like that and give some declaration that, look, we've read this, we understand this, we're doing something different. You haven't come with a single suggestion that something's going to improve. It seems very defensive to me, rather than reflective and some understanding we're going to do better. 

DR CRAWFORD:  I'm sorry I've given you the impression of being defensive, Commissioner. That's certainly not my intent. We have made considerations of the type of training that our staff require. We   as I mentioned in my statement, we do have access to specialist services, clinicians now, so that our Child Safety Officer staff have more disability expertise to consider. We do   and I have in my statement talked about supervision and the other mechanisms that we are trying to take to address the issues that have been identified through this case. So, I'm sorry if that was not as pronounced as it needed to be. 

COMMISSIONER RYAN:  Just one item of detail. On paragraph   line 296 of the agreed statement of facts   I'll read it to you to save you   it says:

    ‘On 7 March 2019 Queensland Police attended Home 2 and the house of Person B, where they located Kaleb. Queensland Police spoke ...’

And so on:

    ‘And they took film on body camera footage.’

And yet later on at line 301, it says:

    ‘There were no records the Department of Child Safety received any child protection notifications concerning Jonathon between 5 April and 31 December.’

I don't see any reference to you receiving a notification from police after that visit. I was just going to ask you, is that because we haven't received it or it's not documented?  Because there doesn't appear to have been a notification from police to your department after that visit. 

DR CRAWFORD:  No, it doesn't appear to be, Commissioner. 

COMMISSIONER RYAN:  Thank you. Thank you, Mr Chair. 

COMMISSIONER McEWIN:  Dr Crawford, one question from me. I apologise, I can't find the specific reference. It was in relation to the situation where your department officials, or the case workers, had attended the home and then spoke to the school and were satisfied that because the boys were attending school and this was regularly, there was no further action. Is that a usual practice for the   your department, when a similar situation like that happens elsewhere, that you rely on the school and the engagement through the school as satisfactory, irrespective of what might be happening at home? 

DR CRAWFORD:  Commissioner, not irrespective of what's been happening at home, but we certainly do have strong partnerships with the Department of Education, and we do rely on the information that they can provide us around children's attendance at school, and their general wellbeing. So, we have strong partnerships with education. 

COMMISSIONER McEWIN:  Does that mean, then, you rely on the Education Department to then be fixing or addressing the other issues that you've identified   

DR CRAWFORD:  I wouldn't  

COMMISSIONER McEWIN:     at home. 

DR CRAWFORD:  Yes, I wouldn't say we rely on them, but we certainly value the information that they can provide about what they're seeing in the child each day that they are presenting. And, Commissioner, schools are very supportive of a great many families in our community. I know that the Department of Education witness will follow me today, but there are some amazing programs within schools that focus on wellbeing, including breakfast programs and study programs and a lot of wellbeing and safety supports to children that is supplied through Education. 

COMMISSIONER McEWIN:  Alright. I'll close off by saying   suggesting, however, that's not the whole solution. 

DR CRAWFORD:  No, absolutely not. 

COMMISSIONER McEWIN:  No.  And it should not be the whole solution. 

DR CRAWFORD:  No, it should not, Commissioner.

COMMISSIONER McEWIN:  Thank you, Dr Crawford. We're grateful for your ongoing contribution to the work that we're doing here at the Royal Commission. 

COMMISSIONER RYAN:  She's not to be excused. Not excused. 

MS EASTMAN:  I think, Commissioners, can I ask that Dr Crawford not be formally excused, in the, I hope, unlikely event that something arises during the course of the balance of the evidence that Dr Crawford should have the opportunity to respond to from other Queensland witnesses, that I'd like you to have that opportunity. 

DR CRAWFORD:  Thank you. 

MS EASTMAN:  So you don't have to stay in the hearing room for the day but just   I'd like you to have the opportunity if that arises. 

DR CRAWFORD:  Thank you. 

MS EASTMAN:  Thank you, Dr Crawford. Commissioners, I've gone over a little bit of my expected time but could we have a short   very short break to reconstitute the hearing room.

COMMISSIONER McEWIN:  Before we do so, Ms McMillan and other parties with leave to appear, I   yes, are there any questions   

MS McMILLAN:  Thank you, Commissioner, for asking but no, and I'm grateful that Ms Crawford   Dr Crawford may have an opportunity, if necessary, to respond to some issues that are raised today and also she's taken a number of matters on notice, so they will obviously revert back to the Commission. Thank you. Might she stand down, at least, at this stage? 


MS McMILLAN:  May she stand down at this time, yes. 

MS EASTMAN:  She is allowed to leave the witness box. Thank you. 



MS McMILLAN:  Sorry, that was    

COMMISSIONER McEWIN:  Ms McMillan   no, I got that. I need to be clear, because of my deafness, I'm about two or three seconds behind the audio so please bear with me. That's why I don't respond straightaway. I'm sure you're all aware of that. I just want to make that clear for everybody. Can I just check are you clear on the questions on notice? 

MS McMILLAN:  I think so, but what we'll do is we'll write to the Solicitors Assisting and just check that we have them properly to   and, please, no need to apologise. 

COMMISSIONER McEWIN:  Thank you. Alright. Well, Ms Eastman, you were suggesting a very short break? 


COMMISSIONER McEWIN:  If so, for how long? 

MS EASTMAN:  Just, I think, two or three minutes just to reconstitute, and then we'll have a longer break for morning tea after the next witness. 

COMMISSIONER McEWIN:  Alright. Well, on that note, we'll aim for   10.30. We'll come back at 10.30. Thank you very much. 




MS MAHONY:  Chair, the next witness is Hayley Stevenson from the Department of Education,.and Ms Stevenson will take an affirmation.


COMMISSIONER McEWIN:  Thank you. Ms Stevenson, thank you for coming to the Royal Commission and you will be providing us with evidence and for the materials that you've also provided. We're grateful. I'm Commissioner McEwin, this is Commissioner Mason, Commissioner Ryan. The associate, who is just down here to your right, will administer the affirmation. 

THE ASSOCIATE:  I will read you the affirmation. At the end, please say yes or I do. Do you solemnly and sincerely declare and affirm that the evidence which you shall give will be the truth, the whole truth and nothing but the truth? 



COMMISSIONER McEWIN:  Ms Mahony will ask you some questions. 


MS MAHONY:  Your name is Hayley Stevenson, spelt S t e v e n s o n. 


MS MAHONY:  You're the Acting Assistant Director General, Disability, Inclusion and Student Services branch within the Queensland Department of Education? 

MS STEVENSON:  That's right. 

MS MAHONY:  You've prepared a statement for the purposes of the Royal Commission, and that was dated 5 May 2023? 

MS STEVENSON:  I think I have it at 4 May. 

MS MAHONY:  4 May, is it? 


MS MAHONY:  Have you   do you have a statement in front of you? 


MS MAHONY:  And you read that statement just before you signed it? 


MS MAHONY:  And you were satisfied that the contents of that statement were true and correct? 


MS MAHONY:  And there's nothing now that you wish to draw attention to or amend, is there? 


MS MAHONY:  If I can just first of all turn to paragraph 5 of your statement, you talk about your current role, and that role is for developing policy and delivering strategies and services that support student wellbeing, student protection, student behaviour and inclusion of students with disability, culturally and linguistically diverse students and students who identify as LGBTIQ? 

MS STEVENSON:  That's correct. 

MS MAHONY:  Within your portfolio, there's no reference to First Nations students? 

MS STEVENSON:  No, not within my portfolio. 

MS MAHONY:  So is there another focus   another portfolio that focuses on First Nations students? 

MS STEVENSON:  Yes, so we have a First Nations Strategies and Partnership branch, and through all of our work we embed the   ensuring that we address the needs of First Nations students so that goes across all the areas of the portfolio. 

MS MAHONY:  What about those First Nations students with disability?  How does your portfolio interact with the other portfolio? 

MS STEVENSON:  So, we work in partnership on a number of areas, but embedded within our policies and responses around supporting students with disability, it's students with disability who may be First Nations, who may be in care --

MS MAHONY:  Can I ask you to slow down a bit and also speak up so everything's captured, but also to take into account that we have interpreters who are in the room and on the live stream. So, if you can just go back and just speak about that point again, please. 

MS STEVENSON:  So across all of the policy areas in the branch, we embed support for First Nations students across that. That includes if we're talking about supports for students with disability, that would be students with disability who are First Nations, for example, or students with disability who might be from culturally and linguistically diverse backgrounds, or perhaps who are in care. 

MS MAHONY:  So does your unit seek specific advice from the unit   portfolio addressing First Nations students when looking at disability within First Nations student cohorts? 

MS STEVENSON:  Yes, we work closely with that branch. 

COMMISSIONER MASON:  Ms Mahony, may I ask a question. Is there a First Nations person with disability working in the First Nations area or someone with disability? 

MS STEVENSON:  In the First Nations area, I am not aware of if they have a disability or not. That's something that not necessarily has been disclosed to me. 

MS MAHONY:  If I can take you to paragraph 10 of your statement, you speak about   the evidence in the statement is based upon the school and departmental records and on policies and guidelines in place at the time that   you refer to them as Young Person 1 and Young Person 2 were attending the Department of Education educational facilities; correct? 

MS STEVENSON:  That's right. 

MS MAHONY:  So just when we're referring to Young Person 1, you understand that is the person Kaleb? 

MS STEVENSON:  Correct. 

MS MAHONY:  And Young Person 2 is the person Jonathon? 

MS STEVENSON:  That's right. 

MS MAHONY:  So when you reference what you read, did you read the proposed agreed facts? 


MS MAHONY:  And in your statement, you reference a number of documents that have the Disability Royal Commission numbering system. So, for example, at paragraph 34, there's a footnote 5 that references a document QLD, there is then a number of numbers after that. 


MS MAHONY:  Did you read each of those documents that you've footnoted to your statement? 

MS STEVENSON:  Yes, I   yes, I did, and I have them next to me now. 

MS MAHONY:  And when you read those documents, you had no doubt, or no reason to doubt the contents of those documents; correct? 

MS STEVENSON:  Correct. 

MS MAHONY:  You accepted them as being accurate reports by officers of your department? 

MS STEVENSON:  Yes.  Correct. 

MS MAHONY:  Made at the time the report   the document is recorded? 


MS MAHONY:  So other than what is referenced in the footnoting and the agreed facts, did you read anything else in preparation for this statement? 

MS STEVENSON:  I read a number of policy documents and other reports, pieces of legislation, fact sheets, guidance materials. 

MS MAHONY:  If I can take you to   just going back a step first, the documents that you referred to in your statement, you've included them really to support the facts of your statement; correct? 

MS STEVENSON:  Yes. Correct. 

MS MAHONY:  And to support the position that you're putting forward as reflecting your views and beliefs? 

MS STEVENSON:  Yes.  Correct. 

MS MAHONY:  And reflecting what you say the true position for the Department of Education was? 


MS MAHONY:  If I can just take you first to paragraphs 19 to 21 of your statement, it comes under the heading Adjustments and Supports Provided By the Department of Education For Students With Disabilities. And at paragraph 19, you state:

    ‘All State schools, including special schools, are required to make reasonable adjustments under the Disability Standard for education 2005, the Anti Discrimination Act 1991 and the Human Rights Act 2019 ...’ 

Being the Queensland Act. 

MS STEVENSON:  Correct. 

MS MAHONY:  And you describe at paragraph 20 what adjustments are, and you describe them as:

    ‘... measures or actions that address the functional impact of disability on a student's ability to access and participate in education on the same basis as their peers without disabilities.’

MS STEVENSON:  Yes. Correct. 

MS MAHONY:  So a reasonable adjustment operates to enable a student with a disability to participate in education on the same basis as students without disabilities? 


MS MAHONY:  Reasonable adjustments help to reduce the barriers a student may face or encounter because of the disability? 


MS MAHONY:  And there are strategies or supports that will help students with disabilities to attend school? 


MS MAHONY:  And when we look at Kaleb and Jonathon, one of those strategies included supported transport. 

MS STEVENSON:  Yes, that’s correct. 

MS MAHONY:  And you referred to that at paragraph 22 and 23 of your statement. 


MS MAHONY:  And note that there was supported transport for the boys to travel to school when they were at school? 


MS MAHONY:  You say at paragraph 21:

    ‘Adjustments do not usually include measures or actions that would ordinarily be the responsibility of parents and carers, such as providing clothing and food.’

MS STEVENSON:  That's right. 

MS MAHONY:  So, just to be clear, you accept that the provision of food to a student is not a reasonable adjustment. 


MS MAHONY:  And you accept that the provision of clothing to a student is not a reasonable adjustment. 

MS STEVENSON:  Correct. 

MS MAHONY:  They are matters for a parent or a carer? 

MS STEVENSON:  They are additional supports for students, for children, yes. 

MS MAHONY:  Sorry, when you say, ‘They are additional supports’, the provision of food is not an additional support, is it? Isn't the provision of food a basic right as a child? 

MS STEVENSON:  Yes, I guess I was meaning in the context of what a school may do. So, a number of our schools will offer and provide food to students as part of a breakfast program or, at times, will purchase or provide food for individual students. So, it was more that it might be an additional role that a school will do. 

MS MAHONY:  Not a reasonable adjustment, though? 

MS STEVENSON:  Not a reasonable adjustment. 

MS MAHONY:  And were you hearing the evidence of Dr Crawford just before? 


MS MAHONY:  And Dr Crawford spoke about the school breakfast program that Queensland has rolled out in the past? 

MS STEVENSON:  Yes. Correct. 

MS MAHONY:  And that is a program that is supported to ensure that all children, not just children with disabilities, come to school with an appropriate meal in their stomach; correct? 

MS STEVENSON:  Yes. So, I believe it is a different government department that funds a number of non government organisations to provide that service in our schools. 

MS MAHONY:  So those types of supports, though, again are not reasonable adjustments. They're supports to assist children generally; correct? 

MS STEVENSON:  Yeah, that's right. 

MS MAHONY:  If we go over to paragraph 31, you talk about the adjustments made by School 2 to enable Kaleb to access and participate in education. And you set out a number of matters, and at sub section (d) it includes the use of visual schedules to assist with movements. At (e) it includes personal care, providing toileting assistance and the like. And at (f), a high level of supervision to ensure safety. However, you go   if I can take you to paragraph 34, what you say is:

    ‘In addition to adjustments being made to enable Kaleb to access and participate in education, departmental records indicate the school staff supplemented his food, bathed him when he arrived at school, provided clean clothes, supplied nappies for use at school and in the home, dropped Kaleb off at home and arranged a haircut for him in February 2018.’

MS STEVENSON:  Yes. Correct. 

MS MAHONY:  You're not suggesting by the words ‘in addition to adjustments being made’ that each of those or any of those were adjustments, are you? 

MS STEVENSON:  No, I'm referring them to as additional support provided by the school to the students. 

MS MAHONY:  These matters really indicate neglect, don't they? 

MS STEVENSON:  They indicate that additional   that staff felt additional support was required for these students. 

MS MAHONY:  So additional support means bathing a child when they arrive at school. That's additional support, not neglect. Is that what you say? 

MS STEVENSON:  I think when referring to the term ‘neglect’ within the Child Protection Act, I would consider that within, then, the thresholds that are required that it would be neglect resulting in significant harm or risk of significant harm and then the other element of the   of the threshold around the parent, willing and able. 

MS MAHONY:  You're aware, though, aren't you, that the Department of Child Services did intervene and what is referred to as an IPA was commenced in respect of Paul Barrett? 

MS STEVENSON:  Yes. Correct.

MS MAHONY:  So intervention with parental agreement? 


MS MAHONY:  And at the time of the intervention, prior to it, the complaint the school was having to bath, every day, the children; correct? 

MS STEVENSON:  Yes, that's right. 

MS MAHONY:  They were having to provide clean clothes every day; correct? 


MS MAHONY:  The fact of an intervention with parental agreement being made, that occurred because there was neglect; correct? 

MS STEVENSON:  Yes, that's correct. 

MS MAHONY:  And the fact that the school having to provide clothing every day and bathing every day was because of neglect. 

MS STEVENSON:  Yes. Correct. 

MS MAHONY:  So, the school knew that the boys were subject to neglect? 

MS STEVENSON:  And if I recall correctly   yes.

MS MAHONY:  No, I'd like you to answer the question. The school knew the boys were subject to neglect? 


MS MAHONY:  At footnote 34 at paragraph 154 of your statement, 154 makes reference to a desktop audit that indicated there should have been   I'll go back a step. After Paul Barrett had passed away and the children were found in their   the terrible state that they were found in, the department undertook a desktop audit; correct? 

MS STEVENSON:  That's correct. 

MS MAHONY:  And the Regional Principal Adviser of Student Protection conducted that audit? 

MS STEVENSON:  That's correct. 

MS MAHONY:  And they made a finding that there should have been a child protection notification in respect to a lump on Kaleb's head? 

MS STEVENSON:  That's correct. 

MS MAHONY:  Were there any other occasions where that audit recommended other child protection notices should have been made? 

MS STEVENSON:  I believe in reading the materials there was another incident of a similar date in 2018 in relation to some of the concerns about the neglect issues and particularly, then, an indication that the father identified that he's not coping. 

MS MAHONY:  And certainly the department doesn't seek to walk away or step away from that audit that there were clear issues of neglect; correct? 

MS STEVENSON:  That in that   yes. Yes. 

MS MAHONY:  And, in fact, when we go back to paragraph 115 of your statement, paragraph 115 of your statement, which comes under the heading Student Protection Report, you state:

    ‘Departmental records also indicate that School 2 undertook steps to address the immediate needs of Kaleb and Jonathon by providing clothing, food and supporting their hygiene.’


MS MAHONY:  That is a history of the school having to address neglect, isn't it? 


MS MAHONY:  You make reference in your statement at paragraph 34, if you can go back to that, of a haircut being arranged for Kaleb in February 2018. Do you recall that? 


MS MAHONY:  You reference in that document a footnote 5. Did you read that document? 


MS MAHONY:  Do you understand the reasons why the haircut was deemed necessary by teachers? 

MS STEVENSON:  Yes. From my recollection of reading the document, it was because of a smell of urine in the hair. 

MS MAHONY:  And it wasn't a smell of urine on one off, was it? 

MS STEVENSON:  No, I believe it was on a number of occasions, and that's why they felt pursuing a haircut was a good course of action. 

MS MAHONY:  So I'll take you to the document that you rely upon. Commissioners, I understand that the documents have not been uploaded yet to the hearing bundle. I'll simply identify it at this moment and read it out. It is document QLD.0005.0028.1360, and it is at page 30, and I'm helpfully assisted, Chair and Commissioners, it is at tab 81 of the Hearing Book B2. On 13 February 2018, do you see the entry at page 30 of that? 


MS MAHONY:  So 13 February 2018, that is a couple of weeks after school has commenced; correct? 

MS STEVENSON:  Yes, correct. 

MS MAHONY:  So school holidays is to the end of January. 


MS MAHONY:  So the boys have been back at school for maybe two weeks? 


MS MAHONY:  The school organises a person to cut both Kaleb and Jonathon's hair. The school speaks with Paul Barrett regarding the haircut. He's happy for that to occur at school. And then there is a note:

    ‘Confidential and sensitive notes regarding why I wanted to cut their hair. This was not shared with Dad Paul. Jonathon has been coming in a strong urine smell in his hair. We have been washing it and giving him showers and it helps, but the smell of urine is still present, so we are hoping a haircut will help.’

The response to the school of urine in a student's hair is to wash the child and have the child's hair cut. That's the response, isn't it? 

MS STEVENSON:  That's the response that's documented here, yes. 

MS MAHONY:  Not, ‘We should report this to the Department of Child Services.’ There's no report made for that, is there? 

MS STEVENSON:  No, there's report made for that incident, no. 

MS MAHONY:  You would agree though, wouldn't you, a child coming in on a daily basis to school with a smell of urine in their hair that even washing does not get really rid of is a child protection concern? 

MS STEVENSON:  It is a concern, and it is for our teachers and professional notifiers to exercise their professional judgment as to whether that meets the threshold of significant harm and that a parent isn't willing and able. 

MS MAHONY:  The position, though, of educators and support staff in the Education Department is unique, isn't it? 


MS MAHONY:  You heard the evidence of Dr Crawford. Education is an important part of the work of child protection? 

MS STEVENSON:  Yes, I think we provide a very protective role. 

MS MAHONY:  You have a unique role where you have eyes on children who are vulnerable; correct? 


MS MAHONY:  Who are presenting at school with signs that they may be subject to neglect; correct? 

MS STEVENSON:  That's correct. 

MS MAHONY:  They may be subject to abuse; correct? 

MS STEVENSON:  Correct. 

MS MAHONY:  Violence. 

MS STEVENSON:  Correct. 

MS MAHONY:  And the department relies, doesn't it, on mandatory reporters to allow them to be able to investigate whether a concern of suspected harm, significant harm exists? 

MS STEVENSON:  Our staff are not able to investigate. That is the role of Child Safety but we will   

MS MAHONY:  That was my question. The department relies on that so they can investigate. 

MS STEVENSON:  That's right. 

MS MAHONY:  The department relies on Education to make the reports so the experts can investigate; correct? 

MS STEVENSON:  That's correct. 

MS MAHONY:  Staying on page 30, 30 May 2018   so this is the same year; correct? 

MS STEVENSON:  Correct. 

MS MAHONY:  Three months later. 

MS STEVENSON:  Excuse me, sorry, which   what is the page? 

MS MAHONY:  Page 30. 


MS MAHONY:  The first entry on that page above the entry of 13 February. 


MS MAHONY:  Sorry, 23 May. Yes. 

MS STEVENSON:  Thank you. Yes. 

MS MAHONY:  If you go to the details of that entry, the second line:

    ‘In particular over the past two weeks, Jonathon has come to school smelling of a strong dog odour; passing rocks, pebbles, during bowel movements; and given the cooler days, he has still been attending in only a shirt and shorts. The boys' lunches have been limited on a number of occasions.’

So, this is on the back of the school having to cut the boys' hair because of urine smelling; correct? 


MS MAHONY:  Over the past two weeks, coming to school smelling of strong odour of a dog? 


MS MAHONY:  Of passing foreign matters in their bowel movements? And May 2018, 23 May   today's date is 11 May.  Attending school in a shirt and shorts? 

MS STEVENSON:  That's correct. 

MS MAHONY:  Do you agree that each one of those things individually speaks of potential neglect of those children? 

MS STEVENSON:  I agree. 

MS MAHONY:  And, cumulatively, speak of at least potential neglect? 

MS STEVENSON:  I agree. 

MS MAHONY:  No report was made on   about that either, was there? 

MS STEVENSON:  No, there was no report. 

MS MAHONY:  And there's absolutely no explanation that you can offer as to why a report was not made; correct? 

MS STEVENSON:  Correct. Because I don't have   I only have the information written on   on the page. I don't have the other experiences, the other information that may have been available to the professional notifiers. 

MS MAHONY:  Well, it's more than that, isn't it? Didn't your own policies and procedures require you to give primacy to ensure the safety of children attending school? 

MS STEVENSON:  I'm not sure what you mean by that question. We prioritise the safety and wellbeing of our   of students, and I think we   we see the actions of the school as absolutely supporting the students in enacting the Child Protection Act.  It is around ensuring our school staff have the information and the knowledge and the expertise to make a judgment about whether it meets the reporting thresholds as set out in the legislation. 

MS MAHONY:  So, if not two weeks after starting the school term there's a continual smelling of urine in the hair that requires a haircut, if not continuing into May, there's for a period in particular over the past two weeks   so you'd agree that that infers there's been other times as well, but in particular over the last two weeks. You'd agree that's open? 


MS MAHONY:  That there's another intractable smell around the students and adding those other matters, wasn't it obvious that this was a matter that ought to have at least been reported to Child Safety as a suspicion, at least, of possible neglect? Possible risk of harm? 

MS STEVENSON:  Yes. I think that we certainly consider that, and the desktop audit formed   formed that view on that, and the department responded to those findings by delivering intensive professional development around those matters and   

MS MAHONY:  To just that one school? 

MS STEVENSON:  On this occasion, to that one school and it was intensive ongoing professional development on a number of matters around record keeping and of writing reports to Child Safety    

MS MAHONY:  To this one school. 

MS STEVENSON:  To this one school. We also   we have a suite of resources, comprehensive information provided to our school staff on making assessments under the Child Protection Act and other pieces of legislation around harm so that they are able to   to form appropriate judgment and take appropriate courses of action. 

MS MAHONY:  Did you, though, given the very clear   I'll go back a step. That training was necessary because Education perceived that School 2   number 2 failed in their child reporting obligations; correct? 

MS STEVENSON:  It was the view that we saw an opportunity to strengthen their understanding and their approaches around student protection reporting. 

MS MAHONY:  And the reason that you needed to strengthen their understanding and reporting is because they simply were not performing it in a manner expected of them; correct? 

MS STEVENSON:  From what we could see through a desktop audit in written documents, we felt there was opportunities for their approach to be strengthened because there wasn't documentation to suggest that the most fulsome response had been undertaken. 

MS MAHONY:  Well, for many of these issues arising, there had been no response to child services, had there? 

MS STEVENSON:  There had been   there was some conversations at different times. There hadn't been a student protection report other than   

MS MAHONY:  And if the   

MS STEVENSON:  Yes, in 2010. 

MS MAHONY:  So the one report in 2010 for that number of years, almost their entire educational life at that school for both Kaleb and Jonathon, one report? 

MS STEVENSON:  That's correct. 

MS MAHONY:  That's a failing, isn't it? 

MS STEVENSON:  In looking at where this situation ended and looking back, yes. 

MS MAHONY:  And not only looking at where it ended, but looking at the material that the school was aware of, that you have looked at in preparing your statement; correct? 

MS STEVENSON:  Yes. The school took a supportive response, not necessarily a reporting response. 

MS MAHONY:  And in taking this supportive response, it was supporting the immediate needs of the children; correct? 


MS MAHONY:  But it was also supporting the utter neglect that was occurring in the home that led them to come to school every day in the state they came? 

MS STEVENSON:  Yes, and I think over time   and it's evident in the documentation from the school and also from other support services   is that there were periods of time where there were no   like, number of years where there were no concerns raised. So, it did seem that it was sporadic in nature, intensified at some points of time in the students' schooling. 

MS MAHONY:  Is it fair to say, though, that the approach that was taken by the school of, in your words, supporting as opposed to reporting, had the effect of enabling Paul Barrett in his substandard level of care for the children? 


MS MAHONY:  And in terms of those periods where you say no concerns were raised, in circumstances where it was considered the reporting of the school was deficient and could be improved, the lack of reporting could well reflect the fact that they just did not make records of what was being observed? 

MS STEVENSON:  I think there's evidence that records of contacts were being made, and that   so there was   there was a series of documentations being made around a range of matters, communicating with the father, communicating with other support services for the children. So, there was a history of records being made but there were also some gaps that were identified through the audit, and so that was another element, was record keeping, that was addressed. 

MS MAHONY:  So, it is quite possible that the lack of concerns raised is a result of insufficient record making? It's possible? 

MS STEVENSON:  It's possible, yes. 

MS MAHONY:  If I can take you to paragraph 118 of your statement, again, this is still under the Student Protection Report topic. 


MS MAHONY:  You refer to what was required to submit a Student Protection Report as at May 2006. Do you see that? 


MS MAHONY:  And you refer to a risk of harm. They're the words in your statement? 


MS MAHONY:  Is that the words that you've extracted or the school, Department of Education, extracted from the Child Protection Act at that time? 

MS STEVENSON:  From the Act or from our policy. In 2006, I think that would have been from our policy. 

MS MAHONY:  Your policy, though, in terms of assessing risk of harm for children, it was driven, though, by statutory definition of harm in the Child Protection Act? 


MS MAHONY:  So you were also aware   and when you say you, I mean the Department of Education   was also aware that as at May 2006, the Child Protection Act at section 9 sub section (3) noted or stated that harm can be caused by:

    ‘... physical, psychological or emotional abuse or neglect.’


MS MAHONY:  The Department of Education proceeded, didn't it, on the basis that its staff understood the concept of harm within those terms. 


MS MAHONY:  They understood that neglect constituted harm   could constitute harm? 

MS STEVENSON:  Yes, that's correct. 

MS MAHONY:  If I can take you now to paragraph 128, which comes under the heading of Self Harming Behaviours   I withdraw that. It's still under the heading of the Student Protection Reports.  But paragraph 128 refers to Autism Queensland OT describing certain behaviour of   of either Kaleb or Jonathon as self harming behaviours. Can you see that? 

MS STEVENSON:  Yes, I see that. 

MS MAHONY:  And at paragraph 129, you reference it not being uncommon for children with autism to engage in behaviour which can lead to injury. 

MS STEVENSON:  That's correct. 

MS MAHONY:  And you say it's not intended to result in harm or injury and is usually a mechanism to self soothe and communicate needs as a result of some form of anxiety. 

MS STEVENSON:  That's right. 

MS MAHONY:  And at paragraph 130, you form the opinion that the self harm reported appears to be a functional impact of a young person's disability; correct? 


MS MAHONY:  So this was in respect of Kaleb's self harm as reported by   


MS MAHONY:    Autism Queensland occupational therapist? 


MS MAHONY:  Are you rejecting at paragraph 130 the professional opinion of someone from Autism Queensland describing behaviours as self harming? 

MS STEVENSON:  No, I think that   that has accepted that those behaviours were occurring and that an individual management plan needs to be put in place to manage those behaviours. 

MS MAHONY:  But your response at paragraph 130 is that the self harm is actually a functional impact of the disability? 

MS STEVENSON:  Yes, but that   

MS MAHONY:  And in doing that, what you're seeking to do is water down the significance of an OT describing behaviours as self harming; correct? 

MS STEVENSON:  No, I don't agree with that. It is that it   that the response required for those behaviours is an individual management plan response by the schools. It's not accepting that we want those behaviours to continue or that those behaviours are inevitable. It's identifying that they're occurring and that the school needs to look at those behaviours and to implement a management plan to reduce the likelihood of them reoccurring, the severity of the impact on them occurring, so to determine what the function of that behaviour is for the young person and to develop a plan to meet the function of that behaviour in another way. 

MS MAHONY:  And you were expecting School 2 to do that upon that report being received by the Autism Queensland OT? 


MS MAHONY:  And at paragraph 132 you state:

    ‘The school records do not directly address whether specific supports were provided to address this concern.’

MS STEVENSON:  That's correct. 

MS MAHONY:  And over at paragraph 135, there is another reference to Kaleb engaging in behaviours of increased hitting his head with the palm and spitting, his teacher hypothesising that he had potential stomach issues and suggesting the young person needed a medical review; correct? 

MS STEVENSON:  That's correct. 

MS MAHONY:  And at 136, you reject that behaviour as being self harming behaviours   the hitting the head with the palm   and you say it's likely the result of disability? 

MS STEVENSON:  Yes, that's   that's correct. 

MS MAHONY:  Again, what you're seeking to do in that is to diminish the fact that a child with a disability may be displaying self harm behaviours and you were simply attributing behaviours to a global disability response; correct? 

MS STEVENSON:  It is, looking at what the function of the behaviour may be, to then design a response that reduces the likelihood and severity of those behaviours continuing into the future. 

MS MAHONY:  I don't think that was the question I asked. 

MS STEVENSON:  Okay. What was   what was the question? Apologies. 

MS MAHONY:  I will approach it a different way. Were you here for the last evidence? 


MS MAHONY:  You heard about the unconscious bias? 


MS MAHONY:  What I want to suggest is that your position at paragraph 130 to 135 is a clear example of unconscious bias where you're looking at a child's behaviours and explaining them solely through a lens of disability as opposed to taking on board expert view that may suggest the child is, in fact, self harming in spite of having a disability, or in addition to having a disability? 

MS STEVENSON:  Okay. That was not the intention of that. It was about looking at the function of the behaviour   

MS MAHONY:  So but that's   

MS STEVENSON:    and addressing it. 

MS MAHONY:  That's the effect of your statement, isn't it, that you have looked at Kaleb as simply a child with a disability and all behaviours can be attributed to that disability? 

MS STEVENSON:  No, I   I reject that. I'm looking at a report saying that Kaleb is engaging in self injurious behaviour that we see frequently displayed in   in children who have autism or other   other concerns, and that then the response needs to address the functions of those behaviours, and I think there is evidence through the case notes of the interventions that the school had put in place around identifying some of the triggers and the escalating behaviours that they might see in Kaleb, and how to intervene. So, it was identifying that those behaviours are likely associated with the disability, but in no way accepting that that doesn't mean that we need to address   address the functions of the behaviours. 

MS MAHONY:  But it was never looked at though in   through the lens that the Autism Queensland OT looked at it as these are self harming behaviours; correct? 

MS STEVENSON:  There's no documentation to suggest that occurred. 

MS MAHONY:  In terms of school attendance during COVID, and you address this at paragraph 50 and 53 of your statement, you say at paragraph 50:

    ‘During this period ...’ 

And ‘this’ means the period of COVID:

    ‘... children of essential workers, children who lived in designated Indigenous communities and vulnerable students could attend school.’

MS STEVENSON:  That's correct. 

MS MAHONY:  And at paragraph 53, you say:

    ‘Vulnerable children who could attend school during school closures included children who received services from Child Safety, including those on a child protection order, and children subject to a youth justice order.’

MS STEVENSON:  That's correct. 

MS MAHONY:  There's nothing in that definition, for want of a better expression, that includes students who have significant needs due to, for example, disability and a lack of parental capacity in the home? 

MS STEVENSON:  No. At that time, there's no reference to that. However, we were learning in this process, and subsequent advice was issued that provided further examples to school   to schools as to what might   on what a vulnerable child, you know, might   might be. So, we realised that that was a narrow definition and we received questions from schools as to would this student qualify as vulnerable and so we issued additional advice to expand on   on that definition. 

MS MAHONY:  So, at the start of COVID, students in the position of Kaleb and Jonathon were not seen as vulnerable for the purposes of being able to have contact in person at a school? 

MS STEVENSON:  Even with the narrow definition, the principals had   had the discretion to accept any vulnerable child   correct, but that was in the first   

MS MAHONY:  Sorry. 

MS STEVENSON:    couple of days. 

MS MAHONY:  The question was:  children such as Kaleb and Jonathon, did not fall within the definition of ‘vulnerable’? 

MS STEVENSON:  In the first   in the early days of the definition. 

MS MAHONY:  At paragraph 58 and 59 of your statement, you say that:

    ‘Parents determined whether their child attended school during COVID 19 school closures. Schools could not compel parents to send their children to school, and that some parents with students with a disability were reluctant.’

MS STEVENSON:  That's correct. 

MS MAHONY:  You're not suggesting, are you, that Paul Barrett fell into one of those categories of parents, are you? 

MS STEVENSON:  Yes. Well the parent   it was up to a parent to   to decide to send their child to school during the closure period. Some parents with disability, whose children were particularly vulnerable to illness   

MS MAHONY:     this about Paul Barrett. Did you find any record that supported Paul Barrett was informed that he could send Kaleb and Jonathon to school during COVID? 

MS STEVENSON:  I'm unaware of any records that indicated that. I am aware that school packs were delivered to the home. 

MS MAHONY:  Okay. Were you aware whether anyone attended on his home to inform him of any changes of the definition of ‘vulnerable’ so that Kaleb and Jonathon could attend school? 

MS STEVENSON:  I'm not aware whether that occurred or not. 

MS MAHONY:  In the absence of records, is it more likely that it simply did not occur? 

MS STEVENSON:  I'm not sure because the packs were delivered in person, and so I am not sure of the nature of the conversation that occurred when the packs were delivered. 

MS MAHONY:  Did you seek to make any inquiries or did anyone seek to make inquiries about that? 

MS STEVENSON:  Not that I have in the records in front of me. 

MS MAHONY:  At paragraph 160 and 161, you make reference to the Queensland Family and Children Commission investigation of your statement. 

MS STEVENSON:  That's correct. 

MS MAHONY:  So when did Education become aware that that review was being conducted? 


MS MAHONY:  Was it on 5 June when you received the letter? 

MS STEVENSON:  I believe so. 

MS MAHONY:  And you engaged in that process by providing documents? 

MS STEVENSON:  Yes, that's correct. We provided documents requested from us. 

MS MAHONY:  Did those documents include documents that disclosed confidential information about the circumstances of Kaleb and Jonathon? 

MS STEVENSON:  I don't believe so, because I believe the review was conducted under the legislation   under previous legislation that didn't provide the QFCC with those particular powers. 

MS MAHONY:  What you're referring to is that following that letter on, I think, 1 July of that year, the Child Death Review Board came into play? 

MS STEVENSON:  That's correct. 

MS MAHONY:  And it was anticipated that that board would undertake a parallel investigation? 

MS STEVENSON:  Yes, we were advised that there would be a further review enacting the new powers in regards to that matter. 

MS MAHONY:  Did that advice impact on the department's decision to investigate the circumstances of Kaleb and Jonathon's experience at school? 

MS STEVENSON:  Our   our investigation occurred prior to 5 June so prior to receiving the initial advice from the QFCC about their internal review. 

MS MAHONY:  And is that that desktop review, the desktop audit that you're referring to. 

MS STEVENSON:  That's correct. 

MS MAHONY:  That suggested there were two occasions where child protection reports could have been made throughout the whole duration of the boys attending that school? 

MS STEVENSON:  That's correct. 

MS MAHONY:  When the report by the Queensland Family and Child Commission was prepared, that was provided to the Attorney General? 

MS STEVENSON:  That's correct, I believe so. 

MS MAHONY:  The Attorney General provided it to various ministers. Are you aware whether the Minister for Education received that? 

MS STEVENSON:  I'm aware that the department received the report, and so I assume that was through the Minister, but I could check that. 

MS MAHONY:  And that report is the unredacted report. So, it had Kaleb and Jonathon's names.  It had the circumstances of their home life, the circumstances of their school? 

MS STEVENSON:  I believe so, but I would   would like to check that to confirm. 

MS MAHONY:  Were you provided with a copy of that report? 

MS STEVENSON:  Yes, I was. 

MS MAHONY:  What did you do with that report? 

MS STEVENSON:  We reviewed the findings of relevance to us. They were mainly in relation to the definition of ‘vulnerable’ – ‘vulnerable child’, as you pointed out, for during the school closure period and ensuring greater supports and reaching out to schools so that they were able to communicate proactively with parents about sending their   their vulnerable child to school. 

MS MAHONY:  So it was quite a limited scope in terms of how Education read that report? 

MS STEVENSON:  Well, they were our findings for consideration   for our consideration. 

MS MAHONY:  You're aware, aren't you, that the report that was due to be undertaken by the Child Death Review Board did not occur? 

MS STEVENSON:  I only became aware of that when I listened to the Commissioner's   

MS MAHONY:  Evidence yesterday. 

MS STEVENSON:    evidence yesterday. 

MS MAHONY:  Given   you've read the proposed statement of agreed facts relevant to Queensland, haven't you? 


MS MAHONY:  You've read an awful lot of documents from the school; correct? 

MS STEVENSON:  Correct. 

MS MAHONY:  Given the fact that the Child Death Review Board did not undertake a deep dive review, and the Department of Education only undertook a desktop audit, in light of all the information that you now have, do you consider that there would be utility to Queensland Department of Education in conducting a much more detailed review that addresses the management of child protection, children with disabilities and reporting? 

MS STEVENSON:  I think there's potential for that to be valuable to us in following the processes that our Child Death Review team now undertakes, as they have done since 1 July. I do agree that   that we can strengthen our   our approach in   in supporting students with disability and ensuring they have particularly a voice around their own safety. So, I think that there is improvements we can make. 

MS MAHONY:  And given that view, is it a position that you would be advocating for such a review to, in fact, take place? 

MS STEVENSON:  I hadn't turned my mind to it previously, but I think that there's an opportunity for us to certainly learn a lot from this case so would be supportive of a review being conducted. 

MS MAHONY:  In terms of Kaleb and Jonathon, how they presented to school over many years as captured in the documents, you would accept that there were signs available to staff and teachers of Education of actual or potential violence, abuse, neglect and deprivation of their rights while they were in their father's care? 


MS MAHONY:  And you would also accept that they were, in fact, subject to violence, abuse, neglect and deprivation of their rights during their period of time at school by reason of their father's care? 


MS MAHONY:  Do you accept that it didn't have to occur? The fact of that disability did not mean that they had to be subject to the neglect, abuse, violence and deprivation of their rights? 

MS STEVENSON:  Absolutely. 

MS MAHONY:  And the Department of Education, it could have done much more by reporting concerns to either limit or to help stamp out that neglect, violence and abuse Kaleb and Jonathon suffered. You'd agree with that, wouldn't you? 

MS STEVENSON:  We would   yes, I agree there were opportunities for that reporting to have been strengthened. 

MS MAHONY:  And not only opportunities. They, in fact, should have done more to protect those children, young people, to protect Kaleb and Jonathon from the violence, abuse, neglect and deprivation of their rights that they did suffer? The department should have done more, shouldn't they? 

MS STEVENSON:  In looking back, yes, we should have done more. I think there is evidence of the school implementing a great deal of supports for   for both the students. So, yes, it's to   that the   while, yes, there could have been more reporting, I think it speaks to the support that schools provide our students that schools do go above and beyond in the support area, and so I guess I just wanted to put that on the record, that our schools do  


MS STEVENSON:  They do implement a number of actions. 

MS MAHONY:  If I could say this, clearly, the   Kaleb and Jonathon, the school staff tried to make their lives better. 


MS MAHONY:  But you'd have to accept in doing so, they enabled the behaviours of Paul Barrett? 


MS MAHONY:  And they did not appropriately respond to the apparent child protection concerns as they were presented? 


MS MAHONY:  Commissioner, they're all the questions that I have.

COMMISSIONER McEWIN:  Thank you, Ms Mahony. Ms Stevenson, I'll ask my colleagues if they have any questions. Commissioner Ryan. 

COMMISSIONER RYAN:  Thank you, Mr Chair. Look, for a moment I'd just like to focus on what schools do, which is teaching and learning. I accept all the   I don't want in any way want to trivialise the other things, but one of the contributions you could have made through schooling is teaching and learning. Would you agree with me if the young men were able to express themselves better they might have been able to explain their condition better to community services officers or others that they were in trouble? 

MS STEVENSON:  Yes, possibly if they were able to express them themselves   and I think in the materials, you can see that there was extensive work around trying   attempting to support the boys' communications, an extensive communication plan and strategies around understanding and facilitating that communication with the boys.

COMMISSIONER RYAN:  You also would agree that the two boys spent most of their time in a special education development unit, which is a school, I understand, specifically designed to meet the needs of people with disability better than any other circumstance, perhaps.  You've described in your statement at paragraph 31 that:

    ‘The boys received a highly individualised curriculum to year 10 and then ...’ 

So, what did you mean by highly individualised? 

MS STEVENSON:  In that it would take into consideration the boys' cognitive development, their communication skills, their interests, which   which throughout the documents, you can see that staff have identified Kaleb and Jonathon's different interests and tailored the education and engagement around those. They also in the records show some of the   the really positive experiences that the schools provided to both boys, such as they attended school camps every year, went to the Ekka excursion, went to the planetarium. So, they had a rich experience at the school. 

COMMISSIONER RYAN:  Sorry, but I'm   first of all, in regard to individualised, I can't help but notice the description of the individualised program received by both boys appears to be almost exactly the same in your statement. So, they weren't individualised in terms of each other. But among the things you've listed is you were supporting Kaleb's aspirations to work in supported employment or a volunteering role. How did you determine that he had an aspiration to work in a supported employment or volunteering role? 

MS STEVENSON:  Based on the documentation through the communication that staff would   would have with Kaleb, through the communication tools such as the PODD book and their other augmentative communications, and as you probably have been out to many   to many schools and seen the efforts that our teachers and teacher aides go to to ensure that students have a   have a voice and have an agency.

COMMISSIONER RYAN:  You do, in fact, refer to the use of the Pragmatic Organisation Dynamic Display books. There doesn't appear to be any evidence that that was ever used at home or used   was the school having any success with that? 

MS STEVENSON:  I don't have that in   in my records as to any of their attempts, that I can recall, anyway, to have Dad engage in that. 

COMMISSIONER RYAN:  We don't have a long time for a long investigation of this, but by all reports by other people who interact with the boys, they basically describe them as nonverbal and not able to communicate in any way, yet it appears there's a miracle going on at school that they're communicating with books. Is there not a possibility that maybe that wasn't happening at school? 

MS STEVENSON:  I looked, read the materials and saw that the staff have identified that body language was a really strong mechanism to use, and I believe might have been Jonathon who displayed 50 percent accuracy around the use of other   other words. So, the school was continually attempting to increase their communication. And in reading the Autism Queensland reports as well from the weekly sessions there, you could see that there   while it did wax and wane over time, that the communication skills improved over time, and they were able to pinpoint some of those effective communications over time. 

MS McMILLAN:  I just note that this appears to be straying slightly outside of the agreed facts and for procedural fairness and other reasons, we're working to keep it within the agreed facts. 

COMMISSIONER RYAN:  Well, I suppose in your review that you refer to, the desktop review, there's no reference in that to examining the educational program that the boys did as to whether that needed improving. Given that it had a particular potential to impact on many of the other things, surely one of the things the department would look at is whether or not every effort made to educate the young boys could have led to a position where they might have been in a position to speak for themselves, however limited. But the school didn't seem to have achieved that, and I'm just wondering why wouldn't you want to be looking   it's all very well to talk about child protection, but the one thing you'd expect the Department of Education to look at is how do we support these kids through their curriculum and through their learning. Do you agree that there's no reference in your statement to that? 

MS STEVENSON:  Yes, I agree. 

COMMISSIONER RYAN:  Would that be something that might be worthwhile addressing? 

MS STEVENSON:  Yes, absolutely. 

COMMISSIONER RYAN:  That's the only point I wanted to make. Thanks, Mr Chair.

COMMISSIONER McEWIN:  Commissioner Mason. 

COMMISSIONER MASON:  Thank you, Chair. Sorry, this air conditioning in this room takes my voice away. I'm interested in asking a similar question I asked previously about that phrase, ‘Nothing about us without us’ and to ask your understanding of that phrase? 

MS STEVENSON:  Yeah, that whenever we're making   whenever we make decisions about you, they need to have an active voice in the decision making, and I can see that we have some ways to go to ensure that students with disability have an active voice at all times in decision making. I do see that occur in the schools when I've been on school visits, that   an example was a recent school visit where the students who were in year 12 showed me through their storyboards that were up on the walls that were describing what their future aspirations were through the images that they   that they place up there. So, I think our school staff endeavour to ensure our students have a voice in the decisions about them. 

COMMISSIONER MASON:  And what's your understanding of ableism? 

MS STEVENSON:  That we come from that conscious   unconscious bias of viewing the world   viewing the world from a perspective that we all have the same abilities. That, I guess, that's the starting point as opposed to looking for those opportunities and actively ensuring that there are no barriers to people being able to actively participate. 

COMMISSIONER MASON:  Ms Mahony went through a number of incidences with the boys, one or both, with their   with the concerns that the school was seeing such as urine in their hair, passing foreign objects like rocks, strong dog odour.  And we have heard today that there were no reports made to Child Safety. And reflecting on that, if it was a   if it was a child without disability, would that situation warrant the same decisions made by staff in the school? If they were seeing children, two boys in the same family   


COMMISSIONER MASON:    and having to be provided with additional assistance by teachers because they needed breakfast or they needed clothes, they needed washing, they were passing foreign objects, if it was   if it was children who could speak up for themselves, if they weren't children with disabilities, would it be seen as   it wouldn't be any different in the way that the circumstances transpired? 

MS STEVENSON:  I've reflected on that in looking at the statement and the materials. I know firsthand that our schools will provide those additional supports to any student that requires them, whether the student has a disability or not. I know that schools also take into consideration and weight very heavily the ability of parents to support. So, I actually looked at   at our Student Protection Reporting data to see if that   if there was any trends in there, and we actually see that 40 percent of the student protection reports submitted by our schools every year   and that's sort of upward of 25,000 reports each year   40 percent relate to students with disability, whereas students with disability only comprise 20 percent of our student population.  So our staff are reporting concerns around   around that, but our schools also provide those additional supports to a range of students who may need them. 

COMMISSIONER MASON:  Do you think those examples that Counsel Assisting has read out and I've read out, that an ordinary person would look at those circumstances and see that there   that it could be perceived as ableism by the teachers, in that it wasn't to do with the disability, they needed other supports to be given to the students, to the two boys, and that they needed to have a level of protection because of what was happening at home? 

MS STEVENSON:  Yeah, I think you could   it could be reasonably perceived as that. 

COMMISSIONER MASON:  Thank you for your evidence today. 

MS STEVENSON:  Thank you.

COMMISSIONER McEWIN:  Ms Stevenson, one question from me, and it relates to paragraph 31. Commissioner Ryan asked you about 31, sub clause (b) and then sub sub clause (1) about transition to life after school which concluded:

    ‘His aspirations were in supported employment or a volunteering role.’

Is there anything on the record in your school records   did they talk about aspirations to go into mainstream open employment? 

MS STEVENSON:  Not that was recorded in the documents that I was able to see.

COMMISSIONER McEWIN:  We've heard a lot in this Royal Commission about the polished pathway. Are you familiar with that phrase? 


COMMISSIONER McEWIN:  The polished pathway described where we've heard about disabled kids going straight from special school to sheltered workshops. So, reading your statement alone just confirms the low expectations that schools have of disabled students. Do you agree with my proposition now, that you've got no records of talking to Kaleb or Jonathon about their aspirations for life after school   straight to a   what we call now an Australian Disability Enterprise, formerly known as   or still known as sheltered workshops. Do you agree with my proposition that reading your statement alone confirms the low expectation that you have of kids with disabilities? 

MS STEVENSON:  I confirm that that's how it could be read in this case.

COMMISSIONER McEWIN:  Alright. I might   well, I've finished my questions. Ms McMillan? 

MS McMILLAN:  Yes, I have a couple of questions, thank you. Ms Stevenson, you were asked earlier by Ms Mahony in the passage of evidence, she asked:

    ‘The fact of an intervention with parental agreement being made, that occurred because there was neglect. Correct?’

    ‘Yes. That's Correct’

She said:

    ‘And the fact that the school are having to provide clothing every day and bathing every day was neglect?’


    ‘So, the school knew that those boys were subject to neglect?’ 

And you answered:

    ‘And if I recall correctly ...’ 

And then Ms Mahony said:

    ‘That wasn't the question.’

What were you going to add at that time? 

MS STEVENSON:  And if I recall correctly, it was that the school then saw an improvement in the boys' conditions and a decrease in their need to provide those supports when there was the IPA in place. 

MS McMILLAN:  Okay. Alright. Thank you. In terms of   you were asked questions about vulnerable students during the COVID period and you said ‘in the early days’ that they would not have fallen within that definition. When you say ‘early days’ what would you mean by early days? 

MS STEVENSON:  In the first one or two days of the closures, and then we received questions and clarification from schools, so we realised that our definition required a little more detail and so issued that advice. 

MS McMILLAN:  And you talk about school packs.  What were they? 

MS STEVENSON:  So they were the curriculum materials, the lesson plans that the students would be learning from home. 

MS McMILLAN:  That would need to enable them to work at home? 

MS STEVENSON:  Yeah, that's right. 

MS McMILLAN:  Thank you. At that time was Kaleb still at school or was he an adult? 

MS STEVENSON:  He was an adult. 

MS McMILLAN:  Yes. Alright. Thank you. Nothing further for this witness. Might she be excused? 

COMMISSIONER McEWIN:  Yes, I'll just quickly check with the other parties with leave to appear. No. Yes, she may be excused. And I'll now just check, do you have anything more to add, Ms McMillan? 

MS McMILLAN:  No. One thing I have to add, I did obtain instructions, Commissioner Mason, that the Indigenous   the First Nations branch do have one staff member who has disclosed having a disability in that division. We can put that in writing, if the Commission requires it.


COMMISSIONER McEWIN:  Thank you. We appreciate that additional information. Ms Mahony, what next? 

MS MAHONY:  Chair, I think we're going to a morning tea break now until midday. And if I can just note for the parties the pronunciation of my surname is Mahony. So, it sounds like M a r n e e.

COMMISSIONER McEWIN:  Thank you for that clarification. Ms Stevenson, thank you for your contribution. We very much appreciate it. You may be excused. 


COMMISSIONER McEWIN:  And we will now adjourn until 12 noon. Thank you. 




MS EASTMAN:  Thank you, Commissioners, the next witness you will see is here with us in the hearing room, Detective Superintendent Denzil Clark from the Queensland Police Service. What I'm proposing with the Detective Superintendent's evidence is to go as far as I can in the open session, but at the end of that, when I reach that point, I'll ask the Commission to close the hearing room, and the only people permitted in the hearing room will be the Royal Commissioners, the Royal Commission staff and the parties with leave. Other than Detective Superintendent, all other witnesses and anybody else will have to leave the hearing room for what will be a short period of time that, as I said earlier, can be the early lunch adjournment, and I understand the Detective Superintendent will take an affirmation.


MR CLARK:  I will do an oath. 

MS EASTMAN:  I've got the affirmation here. If you prefer an oath, that's fine. 

MR CLARK:  Doesn't bother me. 

COMMISSIONER McEWIN:  Mr Clark, thank you very much for coming and providing your forthcoming evidence as well as the material that you provided. I'm Commissioner McEwin.  This is Commissioner Mason and Commissioner Ryan. If you would follow the instructions of the associate, she will read out what I presume will be the affirmation. Thank you. 

THE ASSOCIATE:  I will read you the affirmation. At the end, please say yes or I do. Do you solemnly and sincerely declare and affirm that the evidence which you shall give will be the truth, the whole truth and nothing but the truth? 

MR CLARK:  I do.


COMMISSIONER McEWIN:  Thank you.  Ms Eastman. 


MS EASTMAN:  Can I confirm you are Denzil Clark? 

MR CLARK:  Correct. 

MS EASTMAN:  And you hold the position of Detective Superintendent of Police, Queensland Police? 

MR CLARK:  Yes. 

MS EASTMAN:  You prepared a statement for this case study in the Royal Commission dated 8 May. 

MR CLARK:  Yes. 

MS EASTMAN:  You've had an opportunity to read the statement? 

MR CLARK:  Yes, I have. 

MS EASTMAN:  And are there any corrections that you wish to make to any parts of the statement? 

MR CLARK:  Not at this time. 

MS EASTMAN:  And they are otherwise true and correct. 

MS EASTMAN:  Now, in the course of preparing the statement, you had the opportunity to read the facts? 

MR CLARK:  Yes. 

MS EASTMAN:  Or proposed agreed facts? 

MR CLARK:  Yes. 

MS EASTMAN:  You also had an opportunity to read a range of documents including a document that was a timeline prepared by your staff on or around late May; is that right? 

MR CLARK:  Of this year. Yes, so there were two timelines, one prepared in 2020 and then an updated version prepared this month. 

MS EASTMAN:  Alright. And based on everything that you've reviewed, you're satisfied, both at the time and you continue to be satisfied with the police responses in relation to Jonathon and Kaleb; is that right? 

MR CLARK:  Yes, I am. 

MS EASTMAN:  And it's your position, is it not, that you have not identified any opportunities for policy or procedure improvement; is that right? 

MR CLARK:  Correct. 

MS EASTMAN:  And have you followed the conduct of these proceedings since Monday? 

MR CLARK:  No, I have not. 

MS EASTMAN:  Has anyone briefed you as to what's occurred over the past two days? 

MR CLARK:  Not in any detail, no. 

MS EASTMAN:  And to the extent that you hold the position that, as far as you're concerned, you're satisfied with the responses and you haven't identified any opportunity for policy or procedure improvement, that is without the benefit of hearing or reviewing the evidence presented over the past few days; is that right? 

MR CLARK:  That's correct. My opinion has been formed on the material available to me prior to that. 

MS EASTMAN:  Alright. Just conscious of the time. We're grateful that you've set out your relevant professional experience in the police service and including particular experience in relation to child protection, and they're the matters set out in your statement from paragraph 2 through to paragraph 4. So, can we take that as read? 

MR CLARK:  Yes. 

MS EASTMAN:  Unless there's anything you want to tell the Royal Commission about your experience? 


MS EASTMAN:  Can I ask you, in the course of your professional life with the Queensland Police, have you ever undertaken any particular training with respect to people with intellectual disability who are victims of crime? 

MR CLARK:  Not that I can recall specifically for people with disabilities. We do have training in relation to vulnerable people. 

MS EASTMAN:  But intellectual disability? 

MR CLARK:  Not specifically that I can recall. 

MS EASTMAN:  Right. Do I take it that in the nature of the work that you've done, you've had some training in relation to children and young people as victims of crime? 

MR CLARK:  Yes. 

MS EASTMAN:  Have you had any opportunity to undertake any training with respect to people with disability who are nonverbal who are victims of crime? 


MS EASTMAN:  In the course of your professional life with police, have you done any training with respect to the rights of people with disability generally? 

MR CLARK:  Not as a specific vulnerable group, but, as again, vulnerable people, we certainly have had a lot of training, of late in particular. 

MS EASTMAN:  When you use the expression ‘vulnerable’ you'd accept this proposition, would you not, that people with disability are not inherently vulnerable but the description of vulnerability arises because of the circumstances around a people with disability? 

MR CLARK:  Yes. 

MS EASTMAN:  You're not suggesting that vulnerable and disability are interchangeable, are you? 


MS EASTMAN:  In terms of the rights of people with disability, have you ever heard of the Convention on the Rights of Persons With Disabilities? 

MR CLARK:  Not specifically, no. 

MS EASTMAN:  When you say ‘not specifically’, what do you mean by not specifically. 

MR CLARK:  I should have said no. 

MS EASTMAN:  You've not heard of it. Have you followed any of the work of this Royal Commission over the last four years? 

MR CLARK:  No, I have not. 

MS EASTMAN:  In terms of general policing duties, do you have any knowledge as to whether or not of police throughout their careers   so I'm talking about people at perhaps a lower level to you and the sorts of police who might deal with the day to day interaction of the community. So, that cohort. Are you aware whether general duties police are required to undertake any training with respect to engagement and communication with people with intellectual disability? 

MR CLARK:  I do not believe we have any training of that nature. 

MS EASTMAN:  And what about people with disability who are nonverbal or require communication in different ways? 

MR CLARK:  There's no specific training that I'm aware of.

MS EASTMAN:  Right. Are you aware that the Department of Children, Youth Justice and Multicultural Affairs has issued a practice kit with respect to children and young people with disability? 


MS EASTMAN:  Has the Department of Children, Youth Justice and Multicultural Affairs   formerly and my shorthand, Department of Child Safety   have they done any work with Queensland Police in relation to identifying risk factors or vulnerabilities, to use your expression, for children and young people with disability? 

MR CLARK:  Not that I can recall. 

MS EASTMAN:  Now, in terms of your professional experience, what has been your professional experience with respect to undertaking an investigation of neglect? 

MR CLARK:  Well, I've been a detective since 1990. From that time, I've been heavily involved in the child protection field and I have conducted multiple investigations of neglect, harm and offences against children. 

MS EASTMAN:  Just on neglect, so that we've got a common understanding  

MR CLARK:  Yes. 

MS EASTMAN:    and it would help me, what do you mean by the expression ‘neglect’ in the context of children? 

MR CLARK:  Failure to provide core services to that child which is detrimental for their physical, psychological or emotional wellbeing. 

MS EASTMAN:  And what would be the indicia of neglect? 

MR CLARK:  It could be their physical state. It could   as I said, it could be an emotive or psychological so I'm not exactly sure the right   

MS EASTMAN:  Well, let me put it more simply. How do you identify neglect? 

MR CLARK:  From our observations and evidence that we obtain from others. So, if you're talking about attending a residence, it may be the state of the house. It may be the relationship between the parents and the child. It may be evidence of   that the   of lack of food, clothing or other forms of care or medical support. 

MS EASTMAN:  And in terms of the number of investigations that you would have done with a particular focus on neglect, are you able just to give us a ballpark figure of the number of investigations? 

MR CLARK:  No, I couldn't. It's very rare that you would do just a neglect investigation. Usually there would be some other type of harm that we would be investigating   so, physical, sexual   as well that goes with that, or as part of doing those investigations, you will see signs of potential neglect. 

MS EASTMAN:  And is there any particular sort of matrix or guideline as to how a police officer might undertake an investigation in relation to neglect? 

MR CLARK:  I don't know. I don't think we have a matrix as such. We rely on their experience as police officers to determine whether they have concerns or serious concerns in relation to that child and then there's a course of action to be taken. 

MS EASTMAN:  Alright. Now, you've got a copy of your statement with you? 

MR CLARK:  I do. 

MS EASTMAN:  Can I ask you to turn to   sorry, I don't have page numbers   but paragraph 17. 

MR CLARK:  Yes. 

MS EASTMAN:  So, you're telling the Royal Commission that the Queensland Police does not hold the responsibility, one, nor do members possess the expertise, two, to properly assess risk to children to determine if a child has suffered, is suffering or is at unacceptable risk of suffering significant harm? 

MR CLARK:  That's correct. 

MS EASTMAN:  That language comes from the definition of ‘harm’ in the Child Protection Act. Is that where you've got that from? 

MR CLARK:  Correct. 

MS EASTMAN:  So you had regard to section 9 of the Child Protection Act? 

MR CLARK:  Yes. 

MS EASTMAN:  And in terms of that context of harm, you say that's not an area that we as police have responsibility or relevant expertise; is that right? 

MR CLARK:  Yes. 

MS EASTMAN:  And if there is expertise and a responsibility in relation to risk of harm, that's Child Safety, not us; is that right? 

MR CLARK:  Yes. So, we will identify our concerns, and then we will take it to the appropriate authority, which, in this instance, is Child Safety. 

MS EASTMAN:  And at paragraph 18 you say, though, that:

    ‘Queensland Police is responsible for the investigation of allegations of child harm which may amount to a crime and, where warranted, commence criminal prosecution.’

MR CLARK:  Correct. 

MS EASTMAN:  Now, implicit, is it not, in paragraph 18, that if Queensland Police are to investigate allegations of child harm, then Queensland Police need to know and understand what ‘harm’ means. You would agree with that? How can you investigate something if you don't know what it means? 

MR CLARK:  Well, I think we know what harm means. We know the definition under the Child Protection Act. But whether it constitutes a criminal offence is the point being made there. 

MS EASTMAN:  Right. So, do you have to know what the offence is first so that when you investigate for the purpose of identifying an offence, harm might come into the mix; is that what you're saying? 

MR CLARK:  No, what I'm saying is that if we receive information which there is a potential offence or significant harm to a child then we will investigate it, and depending on the facts, we could determine the particular crime. 

MS EASTMAN:  But if Queensland Police do not have the expertise to properly assess the risk of a child suffering significant harm, is that not a limitation in terms of police capacity to investigate allegations of child harm? 

MR CLARK:  No, I see them as two separate pieces. 

MS EASTMAN:  Can I ask you then about the police function in relation to section 364 of the Queensland Criminal Code. No doubt you're familiar with that section. 

MR CLARK:  Perhaps you could remind me. 

MS EASTMAN:  It's called   I don't know if we've got it to come up.

MR CLARK:  Is this cruelty to children?

MS EASTMAN:  It's called cruelty to children under 16. 

MR CLARK:  Yes. 

MS EASTMAN:  It's just coming up on the screen. 

MR CLARK:  Yes. 

MS EASTMAN:  Is that something you're familiar with? 

MR CLARK:  Yes. 

MS EASTMAN:  And no doubt in the course of your professional life and experience in child protection matters you would have had many occasions to consider this particular offence; is that right? 

MR CLARK:  Correct. 

MS EASTMAN:  And you're aware, aren't you, that the   this provision was amended with effect in 2008 and the amendment was to include the definition of ‘harm’ in sub paragraph (2) and to move the description of the nature of harm, which is now prescribed conduct, into sub paragraph (2), but the new part was the inclusion of harm. Are you aware of that? 

MR CLARK:  I wasn't aware of the date, but I have read the section as it exists today. 

MS EASTMAN:  Alright. So this provision has been in operation for some period of time. 

MR CLARK:  Correct. 

MS EASTMAN:  Have you in the course of your professional life had opportunity to charge and then prosecute any offences in relation to section 364? 

MR CLARK:  Today, I don't recall using section 364. 

MS EASTMAN:  You don't recall. 

MR CLARK:  I don't. I may have, but I don't recall. 

MS EASTMAN:  Just looking at the operation of the provision, the offence applies to the person:

    ‘... would apply to the person who has lawful care or charge of a child under 16.’

MR CLARK:  Yes. 

MS EASTMAN:  The elements of the offence is causing harm to the child. 

MR CLARK:  Yes. 

MS EASTMAN:  I'm sorry, I can hear Ms McMillan. Did you want to say something? 


MS EASTMAN:  Thank you. And in terms of the way in which the harm is to be caused, there's prescribed conduct, and if we look at that, that includes, among other things:

    ‘... failing to provide the child with adequate food, clothing, medical treatment, accommodation or care when it is available to the person from his or her own resources.’

You see that? 

MR CLARK:  Yes. 


    ‘... or failing to take lawful steps to obtain adequate food, clothing, medical treatment, accommodation or care when it is not available to the person from their own resources.’

MR CLARK:  Yes. 

MS EASTMAN:  That covers two distinct things, does it not? 

MR CLARK:  Yes. 

MS EASTMAN:  One is if, for example, a person with lawful care   let's say parent, for example   fails to provide within their own resources. That can be conduct that may trigger an element of the offence; you agree? 

MR CLARK:  Yes. 

MS EASTMAN:  And it's likely if the parent doesn't have that capacity, then the failing to take lawful steps to secure adequate food, et cetera, will also trigger the offence; is that right? 

MR CLARK:  Yes. 

MS EASTMAN:  Now there's an element that the person who engages in the offence has to have knowledge or reasonably to have known what would be likely to cause harm to a child. You agree? And then harm covers a range of factors, but it must involve a detrimental effect of a significant nature to a child's physical, psychological or emotional wellbeing. 

MR CLARK:  Yes. 

MS EASTMAN:  So that's a fairly strong provision in the Criminal Code to protect children under 16 from cruelty. 

MR CLARK:  Yes. 

MS EASTMAN:  Are you aware of this provision ever being used to charge any parents in relation to the parent failing to provide adequate food, clothing, medical treatment, accommodation or care? 

MR CLARK:  Well, I do not know. 

MS EASTMAN:  Would you agree that, looking at the whole of the material available to you   so the agreed facts and the material you've reviewed   that it appears that this offence provision was raised only on one occasion over the course of almost a 20 year period? 

MR CLARK:  The specific reference to that, yes. 

MS EASTMAN:  And because you've had the timeline prepared   

MR CLARK:  Yes. 

MS EASTMAN:    and so if you saw language that mirrored this provision, would you assume that whoever prepared that record may have turned their mind to section 364? 

MR CLARK:  That's a presumption, but it's a reasonable presumption. 

MS EASTMAN:  And if the person turned their mind to section 364 or the elements of what would constitute an offence, then there was an awareness that there was an option open to police to consider taking action, for example, in relation to cruelty to a child under 16? 

MS McMILLAN:  Commissioner, I object to this line of questioning. There is a statement of agreed facts. We volunteered statements from various departments to address that and indicative findings. This isn't one of them, for a start. It's unfair. This witness has no notice of this line of questioning, nor has he had the opportunity to prepare such as, ‘Have you known of anyone charged under it?’ With respect, it's not helpful and it's quite unfair to this witness. 

MS EASTMAN:  Well, I'm just going, Commissioner   just going to use the Detective Superintendent's own material. We had agreed on the agreed facts, but the Detective Superintendent has provided his timeline, which includes some new and additional matters, and I should be entitled to be able to examine him on his own material.


MS EASTMAN:  Alright.  So we might go to that material, then, Detective Superintendent. The document which is Attachment 1 to your statement is a table. Do you see that? 

MR CLARK:  So that's   

MS EASTMAN:  Have you got that? 

MR CLARK:  Yes, that's the 2020 timeline. 

MS EASTMAN:  So the 2020 table was prepared shortly after the passing of Paul Barrett, where various agencies were reviewing what documents they had; is that right? 

MR CLARK:  Correct. Yes. 

MS EASTMAN:  And was this table prepared as part of the preparation of material to provide to the children   sorry, the Queensland Family and Child Commission for its review? 

MR CLARK:  Yes. 

MS EASTMAN:  Did you provide this table? 


MS EASTMAN:  Why not? 

MR CLARK:  It was never requested, and the QFCC review was in two parts, as requested by the Attorney General. So, the first one was a systems review in relation to children with disabilities during the   or vulnerable children during the period of COVID. And then the second part was a specific review in relation to this family. That second part of that review never occurred so we were never required or requested to provide this material. 

MS EASTMAN:  What material did you provide to the QFCC for the systems review? 

MR CLARK:  Policy and procedure. 

MS EASTMAN:  And so this table that you prepared was in anticipation of providing information to the board, if the board was going to undertake a review? 

MR CLARK:  No. No. 

MS EASTMAN:  It wasn't. 

MR CLARK:  So the   prior to the Child Death Review Board commencing on 1 July, there was   we had a series of reviews conducted by QFCC as directed by the Attorney General. So, this was, I think, the third or the fourth one that we were going through, so we were in a pattern of what material would be requested by QFCC. So, in preparation for that, I had asked this to be prepared. 

MS EASTMAN:  Alright. And you thought it would be helpful to the Royal Commission to see the document that you prepared? 

MR CLARK:  I thought it was, yes. 

MS EASTMAN:  Alright. So, let's go to Attachment 1. And the table sets out the date, the relevant subject matter and there's some material there that is covered by the non publication order, so I'll just use the pseudonyms for working through this document. 

MR CLARK:  Sure. 

MS EASTMAN:  Then there's the Action and then the next column has Source and there's a reference there to QPrime. 

MR CLARK:  Yes. 

MS EASTMAN:  And QPrime is the Queensland Police Records and Information Management Exchange? 

MR CLARK:  Correct. 

MS EASTMAN:  And that is a database that commenced operation in June 2007. You're aware of that? 

MR CLARK:  Yes. Yes. 

MS EASTMAN:  It replaced the old CRISP system. 

MR CLARK:  Yes. 

MS EASTMAN:  And so that records that were in the former record management system were then transferred over to QPrime; is that right? 

MR CLARK:  Correct. 

MS EASTMAN:  And QPrime operates by the relevant police officers having to record any particular event and that, in some cases, there's a process of filling out templates, forms in a computerised way? 

MR CLARK:  Yes. 

MS EASTMAN:  I can't quite explain that particularly well. 

MR CLARK:  Yes. 

MS EASTMAN:  But they would pull up on the screen, and if, for example, they were attending a domestic violence incident, then they would then code the responses by reference to that particular incident; is that right? 

MR CLARK:  Yes. 

MS EASTMAN:  And are we right in understanding that with respect to the coding for family violence, that there is not a particular disability flag? Are you aware of that? 

MR CLARK:  Are you referring to police referrals or are you referring to QPrime and the occurrences itself?? So there's two parts to this. So, QPrime is our primary information system where we record, as you said, events and proceedings. Normally, we're talking about offences   list of offences and other actions. I'm not aware whether we have disability   I'm not sure why we would just have disability. There would be a reason attached to the disability that we'd be attending. So, I'd expect, as an occurrence, we would be capturing it under that. 

Under the Police Referral system, which is how we refer people who need support or request support to service providers, that's the Police Referral system which sits   is attached to QPrime so we can make referrals from QPrime through Police Referrals to service providers.  In that system, we don't have disability as a specific referral category. What we do have is 22 other categories, and within those, we can provide information that this person does have a particular disability. 

MS EASTMAN:  Alright. So, just looking at the table you've prepared where you've got in the column Source and a reference to QPrime   

MR CLARK:  Yes. 

MS EASTMAN:    then is the content that's in the column Action taken directly from the QPRIME record? Or is it a more edited version, do you know? 

MR CLARK:  No, it's a summary. 

MS EASTMAN:  A summary. So, the QPrime primary record might have more information in this. 

MR CLARK:  Yes, it does. 

MS EASTMAN:  And in terms of preparing this table and what is included in the summary, was that your decision as to what was included in this document? 

MR CLARK:  My decision. I'd asked for a summary of each of the events to be recorded so   

MS EASTMAN:  So somebody else might have prepared the summary and then you've reviewed it. 

MR CLARK:  That's exactly what happened. 

MS EASTMAN:  The next column is said to be QPrime Reference Number and you'll see there's a reference number there. Does that mean that if somebody enters the QPrime software system and they want to look up a particular event, they can use that number to identify an event? 

MR CLARK:  Correct. 

MS EASTMAN:  If, for example, they wanted to put in the name Kaleb, surname, would the QPrime allow whoever was making the entry, or wanting to check earlier entries, to be able to identify, say, Kaleb by name as either a victim, a perpetrator, whoever it might be under the circumstances. 

MR CLARK:  Yes. So, it's got multiple search capabilities so you can search under multiple entities. You can do it via a person, and if you search via the person, you would see a list of all the occurrences that that person appears in and there's a short title in the front page, so you can very quickly identify what those occurrences are about. It might say ill treatment of child. It might say assault occasioning bodily harm, so domestic and family violence. You could very quickly have a look at that by person. You could also do a search by address, so you could bring up all the of the incidents recorded to a particular address.  And then once you enter each of those incidents, you can see the involved people, et cetera. 

MS EASTMAN:  And in the ordinary course, say, for example, police officers were called out to a particular incident at a particular address, would there be capacity for the officers to check the QPrime before they went out? 

MR CLARK:  Yes, there's two parts to that one as well. So, if it's a job detailed by the Police Communication Centre, they do checks themselves to provide brief information to the investigating officers. Particularly around safety concerns so firearms, et cetera, violence. But the officers now with their mobile capabilities en route can do checks themselves on QPrime to inform themselves about the address and the people. 

MS EASTMAN:  Alright. Now, you'll be pleased to know I'm not going to ask you about every event in your table. 

MR CLARK:  Thank you. 

MS EASTMAN:  But there's three that I do want to ask you about. So, the first one, if you can   and, again, I don't have page numbers so I have to work by date. 

MR CLARK:  Yes. 

MS EASTMAN:  But it's the second page in the table and the entry date, Commissioners, is 03/03/2010, so 3 March 2010. Have you got that, Detective Superintendent? 

MR CLARK:  I do. 

MS EASTMAN:  Now the heading here is Offences Against Children, Ill Treatment, do you see that? 

MR CLARK:  Yes. 

MS EASTMAN:  Can I summarise it this way:  that there was a notification from Kaleb and Jonathon's school indicating that:

    ‘Kaleb and Jonathon presented at school in poor condition with poor quality food and showing signs of hunger on a regular basis, concern that bowel motions on a regular basis contained foam rubber, possibly from home lounge or mattresses. House is sparsely furnished and has overpowering smells. The boys are often restricted to one room which has one lounge and very limited toys. The father is said to have some in home support, but it has stopped for unknown reasons, and the boys' health and hygiene has deteriorated.’

So, that's the entry. Now, the language used there, would you agree with me, is the type of language that might pick up the elements of section 364, cruelty to children under 16, and both boys were under 16 at the time. Do you agree? 

MR CLARK:  Yes. 

MS EASTMAN:  This record tells us on 28 May 2010, police attended the family home at that time about 9.30 at night. Now   and you can help me with this   it says:

    ‘Father denied above allegations, and when challenged by police after entering the house and observing issues of neglect, he made excuses or changed his story.’

So, in terms of the record of ‘father denied allegations’, would that suggest that when police went to the family home, that the allegations put to the father were the matters that I've just described in the paragraph above? 

MR CLARK:  I think that's a reasonable presumption. 

MS EASTMAN:  And I'll just jump down a little bit. It says that:

    ‘The police contacted Crisis Care.’

So, that's the police acting and that's part of a referral, is it? 

MR CLARK:  Crisis Care is the after hours Child Safety service.


    ‘Advised an SP4.’

And that's a particular code used? 

MR CLARK:  Yeah, SP4 is an Education report to police for child harm. 

MS EASTMAN:  But this was enough to require police to say something needs to happen, that the police were able to form a view, may I say, of suspected harm to the children. 

MR CLARK:  I think so. As that report proceeds on and they talk about a temporary assessment order et cetera, that is clearly that they have concerns about the safety and wellbeing of those children. 

MS EASTMAN:  Over the page, the record indicates that the police observed that:

    ‘... the children are likely to be lagging in their development more than can be accounted for by their underlying cognitive impairment. The children appear isolated and unlikely to be provided the necessaries ...’ 

Might be necessities but says necessaries:

    ‘... of life by their father.’

And police left at 10 pm. 

MR CLARK:  Yes. 

MS EASTMAN:  The next step was the police contacted after hours Child Safety and arrangements were made for a further attendance the next day to remove the children. Am I right in understanding that that time that the police spent putting the allegations to the father, observing the children and observing where the children were living and their living conditions, that police were able to form a view that the children needed to be removed? 

MR CLARK:  Yes. 

MS EASTMAN:  And notwithstanding your observation that the police did not have the relevant expertise or responsibilities, this appears to be an instance where the police have been readily able to identify the risk of harm to the children and also identify that action needs to be taken in the form of removing the children. You'd agree with that? 

MR CLARK:  So the purpose of removing the children is to allow Child Safety to make a proper   

MS EASTMAN:  I'll come back to the purpose. My question is about the capacity of the police to do what's recorded here. 


MS EASTMAN:  You accept they were able to do that? 

MS McMILLAN:  With respect, the witness was answering the question. It's not fair to cut him off when he was being responsive. 

MS EASTMAN:  Well, I'd ask the witness to be responsive to the question but I think we're getting there, Commissioner. 

MR CLARK:  So, I think there's two points. The assessment of harm sits with the Department of Child Safety. We identify our concerns, and if we believe that those children perhaps are at risk whilst the assessment is occurring, then we will request or, if we have to, we will take action to remove the children to allow that assessment to occur. So, that isn't us determining harm. That is us   

MS EASTMAN:  But there was enough   sorry, forgive me for interrupting, but there was enough there for the police on that occasion to say the children need to be removed. For what purpose follows is a different inquiry. My question to you is the police capacity by their observation, by their engagement with the father, had enough information to decide the children should be removed, for whatever purpose or process comes later. You agree with that? 

MR CLARK:  For a temporary removal till an assessment can be conducted. 

MS EASTMAN:  Okay. You'll seize from the note that the following morning, the police return with Child Safety and this is what's said:

    ‘The environment the children were exposed to was worse in daylight.’

So, the father then consented to the children's removal. 

MR CLARK:  Correct. 

MS EASTMAN:  If the police had not attended on that occasion, and if the police had not made the assessment that the children needed to be moved immediately, would you agree with me that it's unlikely that there would have been anything else that would have happened around that time that resulted in the children being removed? 

MR CLARK:  I can't answer that because I do not know what Child Safety knew. I know that the police were concerned sufficiently they requested the removal of the children whilst an assessment occurs. 

MS EASTMAN:  Alright. So, we know following that this intervention by the police, the children with the consent of the father, were removed for a period of about a week. You're aware of that? 

MR CLARK:  I wasn't. The length of time, I wasn't    

MS EASTMAN:  And the last entry here says   and this comes back to my questions earlier about section 364, it says:

    ‘To substantiate any offence, medical evidence would be required, so proceedings may be commenced upon a recommendation by SCAN. However, at this stage, the offender is being dealt with by DOCS.’ 

Do you see that? It's the last sub paragraph. 

MR CLARK:  Yes, I do. 

MS EASTMAN:  Now, does that suggest to you that whoever made this entry, he or she, may have turned their mind to provision 364 and given considerations to the elements of the offence? You agree with that? 

MR CLARK:  I don't know specifically about 364, but certainly consideration around neglect and care for children. 

MS EASTMAN:  Well, is there another offence in the Queensland Criminal Code about care and neglect of children that would constitute an offence? 

MR CLARK:  There's multiple offences that could apply. So, you have failing to provide necessities of life. Endangering a child. Then you've got the more general offences of torture, deprivation of liberty, assaults, etcetera. So, there are multiple offences that could be considered, not just 364. 

MS EASTMAN:  But can I say, stepping back and looking at this intervention in May 2010, that this was the only time that both Jonathon and Kaleb were removed from their parents   from their father, put aside Kaleb's removal as a tiny infant, this is the only time these children were removed from their father and the living conditions that they were in. Are you aware of that? 

MR CLARK:  No. I'm aware of this occasion. I'm not sure if they had been removed on other occasions. 

MS EASTMAN:  But you're not aware. Can I put to you this is an occasion where the system seems to be working reasonably well. There's a notification from the school. The police act on that notification. The police attend the residence. The police put the propositions or allegations to the father. The police form a view and exercise judgments. It results in action then being taken with Child Safety for the removal of the children, as you say, for whatever purpose comes later, an assessment by SCAN or whatever action is taken. This is an example of the system working well. Do you agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  And when we look at the entire records this is the only time? But you're not aware of that, are you? 

MR CLARK:  Actually removed from that house, no. 

MS EASTMAN:  Okay. I want to take you to the second example now. So, again, it's over the page and I think we'll do the example that starts with the entry date of 10/01/2015. 

MR CLARK:  Yes. 

MS EASTMAN:  Now, that's described as street check. What does a street check mean? 

MR CLARK:  It is where you engage with the person, no particular offence has been identified but you're recording that you have engaged with that person and the nature of that engagement. 

MS EASTMAN:  And would a street check be done by one or two police officers. 

MR CLARK:  It could be done by an individual. 

MS EASTMAN:  Right. So, this records that there was a street check and there are a number of people identified, including Kaleb and Jonathon at a camping ground and another camper had raised concerns over the welfare of the children who are:

    ‘... severely disabled. Children could not speak but appeared okay and fed but had poor hygiene and smelt of urine.’

You see that   

MR CLARK:  Yes. 

MS EASTMAN:    record there? So can we infer this is a summary of a larger record but, in summary, someone has contacted the police to raise a concern about the welfare of the children? 

MR CLARK:  Yes. 

MS EASTMAN:  They recognise the children as children with disability? 

MR CLARK:  Yes. 

MS EASTMAN:  Then there had been the street check and the street check had yielded the result of, ‘They appeared okay, fed but had poor hygiene and smelt of urine.’

So, that might reflect the observations made by the police officers? 

MR CLARK:  Yes. 

MS EASTMAN:  Would you have expected the police officers attending that street check to have reviewed the earlier Prime records? 

MR CLARK:  Possibly. 

MS EASTMAN:  Because if they had reviewed the earlier Prime records, if you can go back, they would have seen that on New Year's Eve on 31 December 2014, about 10 days or so before the camping ground matters, that there had been a police attending at the family home at 8.45 on New Year's Eve? 

MR CLARK:  Yes. 

MS EASTMAN:  And the police viewed the children who were then asleep in the bedroom only dressed in nappies, but appears clean with fresh nappies and seemed well fed? 

MR CLARK:  Yes. 

MS EASTMAN:  And the observations made by the police was, and I'll just drop down a few lines:

    ‘Doorhandles on the inside and outside of the bedroom door had been removed so the children were unable to exit the rooms by themselves. The father stated that the doorhandle had fallen off, but police believe it had been removed intentionally to prevent the children from getting out. The kitchen was filthy, with open tins of food and dirty dishes, but it appears that the basics are being provided by the children. There is insufficient evidence ...’ 

I assume that means:

    ‘... to suggest a criminal offence has been committed, but on this occasion the police also contact DOCS after hours.’

Do you see that? 

MR CLARK:  Yes. 

MS EASTMAN:  So if 10 days before the street check the officers had checked the QPrime in relation to the New Year's Eve matter, do you think that you might have expected the officers to perhaps do a little bit more than simply make an observation that the boys appeared okay? 

MR CLARK:  The street check may not or does not, perhaps, summarise all of the actions taken by the officers. I   I can't say what they did or didn't do. 

MS EASTMAN:  Well, then, moving on, obviously the camping trip continues and by the   on the weekend of the 17th through to 19 January 2015 you can see that there is recorded in your table a Crime Stoppers report. So, Crime Stoppers mean that members of the general public can ring a line and report something that they may see or witness; is that right? 

MR CLARK:  Correct. 

MS EASTMAN:  And no doubt Queensland Police take very seriously a report to Crime Stoppers? 

MR CLARK:  Yes. 

MS EASTMAN:  And it's customary, is it not, that if there is such a report, that the police would then attend? 

MR CLARK:  No, not necessarily. 

MS EASTMAN:  Not always. 

MR CLARK:  No, because Crime Stoppers pass on information for all manner of police, drugs, is very common one. If there's insufficient evidence within the crime report, the Crime Stoppers report, then we perhaps will not take action. 

MS EASTMAN:  Okay. You're familiar, aren't you, with the summary that appears for the entry 19/1/2015?  It's quite lengthy? 

MR CLARK:  Yes. 

MS EASTMAN:  You've read that? 

MR CLARK:  Yes. 

MS EASTMAN:  Alright. Can I summarise it this way   in summarising, not intending to minimise any of this, but it seems that two people who are at the same camp ground had observed Kaleb and Jonathon. They identified or recognised the young men as intellectually handicapped. That's the expression used. And there was a belief that they had been camping for about four weeks. The informant to Crime Stoppers raised the following concerns:

    ‘The boys being left unsupervised for most of the day. Spending most of their time in a tent with temperatures of approximately 35 degrees. The nappies were not changed regularly and smelt very bad. The boys were washed once a day, which involved stripping their clothes and nappies off and throwing a bucket of bore water over them. There was no soap, no scrubbing, and then they were dressed in the same clothes. The father fed the boys in the dark at night, and on two occasions the youngest boy hid behind someone at the camp ground, but the father grabbed him and on one occasion kicked him very hard up the backside. On the last night the informants were there they could hear the father laying into one of them. One of the boys was making a noise in a tent, so the father went into the tent and started smacking him loudly.’

That's the Crime Stoppers report. That would be enough to warrant police to go and follow that up. You agree? 

MR CLARK:  Yes, that's what they did. 

MS EASTMAN:  Well, the police then did not make the camp ground until 22 January. Do you see that? Would there be any reason why it would have taken a number of days? 

MR CLARK:  No, I can't answer what demands were in place on the officers at the time or what resources were available to attend. 

MS EASTMAN:  Would you agree with me, looking at the record of the police attendance, that their engagement was with Paul Barrett and there's nothing to indicate that the police spoke to or attempted to speak to the children at all. You agree with that? 


    ‘Police observed children to be healthy but were obviously wearing soiled nappies.’


MS EASTMAN:  Yes, they observed them but I'm putting to you they didn't make any attempt to speak to them. 

MR CLARK:  I don't know whether they did or they didn't. Just because it's not recorded here does not mean they didn't attempt to speak with them. 

MS EASTMAN:  Unlike the earlier matter that I drew your attention to, there is nothing here that records the police putting those allegations which include, would you agree, assault in relation to the children? Kicking someone up the behind, grabbing or slapping; that's an assault, isn't it? 

MR CLARK:  By definition and you have to consider domestic discipline as well, but I   but I concede. 

MS EASTMAN:  You are not for one second suggesting this is domestic discipline, are you, Detective Superintendent? 

MR CLARK:  What I said was you would have to consider it, but I concede it could be an assault. 

MS EASTMAN:  You concede that. If the informant gave the information of an assault in relation to two children identified as young people with intellectual disability, you would expect your police officers to make a thorough investigation, would you not? 

MR CLARK:  I would expect police to make the appropriate inquiries every time. 

MS EASTMAN:  Looking at the record here, I want to put to you that the response recorded was wholly inadequate, given the information provided by the informant. Would you agree with that? 

MR CLARK:  No, I disagree. 

MS EASTMAN:  You do? 

MR CLARK:  Yes. 

MS EASTMAN:  So even though the police observed the children wearing soiled nappies, they accepted on face value the father's contention that they were changed regularly. That seems to be the effect. 

MS McMILLAN:  I object to that. If Counsel wants to put it fairly, which includes over the page, then that is exactly what she should be doing. 

MS EASTMAN:  And that's what she is doing. 

MS McMILLAN:  Thank you. 

MS EASTMAN:  I'm on the first sentence. 

MR CLARK:  Sorry, you have to repeat that. 


    ‘Police observed children to be healthy but were obviously wearing soiled nappies, which the father stated were changed regularly.’

And what I put to you is this seems to be the police accepting what the father said. You agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  Then the police make an assessment:

    ‘Because the family have been camping for three weeks, the children appeared to be in good health.’ 

You agree, don't you, that your officers have no relevant expertise, do they, to assess or determine harm? 

MR CLARK:  Yeah, that's correct, but what we can do is identify our concerns. If we have serious concerns in relation to a child, through indicias you raised, then we will report it. 

MS EASTMAN:  Okay. But they don't have the expertise to know whether or not a child is or is not in good health? 

MR CLARK:  We have, as everybody does, the ability to make a general assessment or general   form a general view. 

MS EASTMAN:  And there's no signs of injuries and it says:

    ‘Nil child protection concerns. The father indicated he has support from school.’

So the conclusion is, the police state:

    ‘There's no evidence of a criminal offence.’

But you've just agreed with me that the informant's information would constitute an assault. 

MR CLARK:  That's not evidence   

MS EASTMAN:  Do you agree with that? 

MR CLARK:  That's not evidence of an offence. 

MS EASTMAN:  But you agree with me that there's nothing in this record to indicate that the police made any inquiries of Mr Barrett with respect to pulling kids into a tent, grabbing them from behind, kicking the kid up the backside or laying into them or smacking them loudly. There's nothing to indicate that the police raised that with Mr Barrett. Do you agree with that? 

MR CLARK:  There's nothing   I do agree, but there's also nothing to say that wasn't raised with Mr Barrett, and this is a summary of their final outcome or that officer's outcome in which he decided there was no child protection concerns. So, how we formed that opinion   I don't have the evidence in front of me to say what he did or didn't consider. 

MS EASTMAN:  Have you made any inquiries about this particular incident yourself? 

MR CLARK:  No, I've not made any inquiries about any of the incidents, other than what's contained within the QPRIME reports or other material available. So, a desktop exercise is what's occurred. 

MS EASTMAN:  And in terms of this incident, there are no records indicating that this matter was reported to Child Safety. You agree with that? 

MR CLARK:  Yeah, that's correct. If no child harm concerns were identified, then there was no requirement under policy or procedure for it to be reported to Child Safety. 

MS EASTMAN:  Sitting here today, do you accept that the description from the informant clearly identified harm either having occurred or the children being at risk of harm. You'd accept that, wouldn't you? 

MR CLARK:  I wouldn't accept that it's occurred. What they've described is potential that it did occur. The officer assessed it and made an informed decision not to report it. 

MS EASTMAN:  Now, Commissioners, I now want to turn to the next matter, which is recorded in the table, but I need to show the Detective Superintendent some material that I can't show him other than in a way of disturbing the non publication orders, and so for that reason I ask that the hearing room be closed. So, those who need to leave, they have an early lunch.

COMMISSIONER McEWIN:  Yes. So, I will ask members of the public to leave. Those with leave to appear can stay. Commissioners, obviously, and Commission staff. So, anyone else, members of the public to leave and we will come back shortly. So, the Royal Commission is now closed to the people in this room. Can I ask a staff member to check that all members of the public have left. 

MS EASTMAN:  And that includes witnesses as well. So, anyone who's about to give evidence, they cannot remain in the hearing room. They are not a party of this leave to appear.

COMMISSIONER McEWIN:  Thank you. Can we do a final check? Okay. Thank you. Can I just now check that anyone who should have left has left? Can we confirm that with Counsel Assisting? 


MS EASTMAN:  I'm waiting for the LIO team to tell me when they're ready and we'll immediately go into playing the video. Okay. Detective Superintendent, I'm going to show you a video now, it's a video from the body worn camera from Queensland Police officer. The Royal Commission has heard some evidence in relation to [redacted], and this is a video about an interaction between Queensland Police with [redacted] and also with Kaleb. But I'll show you the video and then I want to ask you some questions.

(Video played) 

Transcript of extract of QLD.0008.0029.0653   QPS – body camera footage of attendance at Home 2, 7 March 2019 
POLICE 1: [Kaleb]. 
PAUL BARRETT: [Kaleb] c’mon mate. 
POLICE 1: C’mon [Kaleb]. 
PAUL BARRETT: [Kaleb], c’mon mate. [Indistinguishable].
POLICE 1: All good. Do you want to come out? Can I help you down? 
[KALEB]: No, no, no, no, no, no, no. 
POLICE 1: All good. Do you want to come see dad? Are you alright, if he just comes and grabs him? 
PAUL BARRETT: Come here. [Indistinguishable]. Stay away from my children. 
POLICE 1: Ah, just leave it, just leave it. 
PAUL BARRETT: Stay away from my children [redacted].
POLICE 1: Back in your yard please. Don’t, don’t raise your voice. Um so, we’ll um, we’ll obviously put in a notification through to um Child Safety as well, okay. 
[REDACTED PERSON 1]: Do you want to see the photos of the room? 
POLICE 1: Yeah, I think he said that Child Safety was here this morning as well, so we will just follow up with that as well, from [redacted], so I believe they have done an audit as well. So we’ll um, just double check with [redacted] that, that is the case. Um and go from there. But yeah, I’m sure they would have seen it, but I’m happy to have a look at the photos mate, if you want to. That’s fine. 
[REDACTED PERSON 2]: This is on the 1st of October. You can see them. That’s their whole room. 
POLICE 1: Yeah. 
[REDACTED PERSON 1]: They don’t have any furniture. I 
[REDACTED PERSON 1]: Quite often they sleep on the floor, in winter. In their nappies. 
POLICE 1: Is that a back door or something? 
[REDACTED PERSON 2]: That’s their door. 
POLICE 1: Oh right, okay, okay. 
[REDACTED PERSON 2]: Without a handle. 
[REDACTED PERSON 1]: There was a spoon on it. They couldn’t get out of that room. And [Kaleb], who knows how to get himself a drink, could not get himself a drink. And I’m not the only person to witness this. There are many people who come through.
POLICE 1: No, no, that’s right. Have you forwarded these photos on to Child Safety?
[REDACTED PERSON 1]: Um, they said they couldn’t accept such a large file. Cause I seeing a [redacted] to help me cope with it. Um, [redacted] tried to send it through, um. 
[REDACTED PERSON 2]: Do you want to see? 
POLICE 1: What I would do, is actually just ask them to come and see you. And you can show them. 
[REDACTED PERSON 1]: I was hoping they would do that. 
POLICE 1: Maybe just request that next time, and just say, ‘Hey, do you mind just coming out?’ Um   
[REDACTED PERSON 1]: I rung them before to tell them to come out and see what was going on
[REDACTED PERSON 2]: In their nappies there.
POLICE 1: Today, yep, cool, cool, cool. That’s good. 
MAN: This was a while ago, all the way in October. 
[REDACTED PERSON 1]: It’s very unusual. He left him for a whole hour. 
POLICE 1: Yea, that’s exactly right. 
[REDACTED PERSON 1]: And I think because Child Safety came this morning, that he’s looking for an argument. For a vicious moment, basically.
POLICE 1: Okay. So we’ll follow up with Child Safety and ensure that they um, they did in   , did you see them here in the morning? 
POLICE 1: Okay, I’ll double check they   
[REDACTED PERSON 1]: But there were a lot of people with clipboards yesterday, because my support worker said they were there.
POLICE 1: Okay I’ll um double check that they came out. You’ve obviously made another complaint, I guess, about that today, we’ll follow up with that as well. And um, and go from there. Obviously, they’re   they gunna’ be the lead agency in this. There’s obviously a   
[REDACTED PERSON 1]: I am more than happy with for them to come and interview me.
POLICE 1: Yeah, yeah, and that’s what you   , maybe next time you do speak to them, maybe just say that’s just literally what you’re requesting. Someone needs to come out and look at the photos that we have, the conditions that their living in, um, whether he’s changing their conditions before they get in there. Who knows? You know what I mean? 
[REDACTED PERSON 1]: Oh, absolutely. 
[REDACTED PERSON 2] : It’s all the same from October.
[REDACTED PERSON 1]: He’s just sociopathic.
POLICE 1: Yeah, of course, it’s a delicate situation. 
POLICE 1: Um, it’s an unfortunate situation that ah    we’ll follow up and hopefully they’ll try and do some action okay? Alright. It’s unfortunate. Alright, I would suggest they come out and actually look at the photos themselves okay. Alright. 
POLICE 1: Alright, sorry guys, didn’t help you too much more but we’ll go from there ‘ey and try and get something done. 
[REDACTED PERSON 1]: Thank you. Oh their dog is over there too.
POLICE 1: Over here? 
[REDACTED PERSON 1]: The dog was out [indistinguishable]. 
POLICE 1: Oh okay, I’ll have a look. Do you want me to close the gate up?
[REDACTED PERSON 1]: Yes, thank you. 
CONSTRUCTION WORKER: Hello. We have a dog over here as well. 
POLICE 1: Oh yeah, he’s from there as well. Is he at the back, is he? 
CONSTRUCTION WORKER: Yeah, he’s down here.
POLICE 1: Hey pup [whistles]. Is it their dog?
CONSTRUCTION WORKER: Puppy, puppy. [Indistinguishable]. 
POLICE 1: Is that theirs as well, is it? 
POLICE 1: Oh okay, grab him anyway. Good boy, big boy – Common big boy. Yeah   
CONSTRUCTION WORKER: That rope with him [indistinguishable].
POLICE 1: I’ll bring it back here brother. Pretty sure it’s his dog. C’mon. This way. Paul. That top thing, and move that top thing, yeah that’s good. 
PAUL BARRETT: I brought him [indistinguishable].
POLICE 1: No. Your dog. 
POLICE 2: Is this your dog? 
PAUL BARRETT: Yes. [Redacted Person 1] took my dog too. That would be right.
POLICE 1: What are you doing mate? You’re a big boy. Nah, your dog was actually at the construction site. It run into there. It was never [redacted]. 
PAUL BARRETT: [Redacted Person 1’s] making up all [indistinguishable].
POLICE 1: Yeah but that’s alright [indistinguishable]. Nice and friendly. 
PAUL BARRETT: Oh, he’s very friendly. 
POLICE 1: C’mon mate, inside. 
PAUL BARRETT: Come in here you dumb shit. Come on.
POLICE 1: No, no, it’s just to    they had him tied up mate, cause they didn’t know where he lives. 
PAUL BARRETT: Mate, they’ve been in the house – they’ve working there for two months, they know exactly where this dog lives. 
POLICE 1: Mate, I don’t know, mate. Go inside, brother. See ya’, mate. There you go. 
PAUL BARRETT: [Indistinguishable] You dumb shit.
POLICE 1: There you go. Alright, all good. Thanks mate. Do you know ah, so that um, [redacted] Child Safety? 
PAUL BARRETT: Yes mate. 
POLICE 1: Okay, beautiful. 
PAUL BARRETT: Now, [redacted Person 1] has been coming to my back door. I’ve been coping crap from [redacted Person 1] for a while. I’ve even actually rung up [redacted] police to ask to have the police several times about [redacted Person 1]. I’ve even had [redacted] police out here talking to me about [redacted Person 1]. 
POLICE 1: You might need to get some cameras mate. I know – I’m just     if – you can see who does it then, if that’s your allegation, you know you might need some cameras okay. 
PAUL BARRETT: Mate, Child Safety have been out many times [redacted], [redacted Person 1]  [indistinguishable] with lies, [redacted Person 1] has to come. They come in the house, they check   
POLICE 1: Yep. 
PAUL BARRETT: They leave. 
POLICE 1: Yep. 
PAUL BARRETT: They’re sick of it too.
POLICE 1: Yep, nah ‘ats alright.
PAUL BARRETT: We’re all bloody sick of it.
POLICE 1: Well we’re only here today because [redacted]   obviously, was just, a child was out, that’s the only reason, and the dogs. 
PAUL BARRETT: [Indistinguishable] If he was a there for an hour, if [redacted Person 1] was a halfway decent [redacted], [redacted Person 1] just would have just yelled out. 
POLICE 1: Yep. 
PAUL BARRETT: If [redacted Person 1] was a half way decent [redacted], [indistinguishable] I know, I know. 
POLICE 1: That’s it mate, but this is the situation we are in now, isn’t it? 
PAUL BARRETT: [Redacted Person 1’s] actually an ex. [Redacted] 
POLICE 1: Alright. Okay. 
PAUL BARRETT: [Redacted]. I found out, I said ‘piss off, get out of my house and don’t come back’ and I’ve been coping shit ever   . 

(Video stopped)

MS EASTMAN:  Okay. We've showed that. There's bits of the video at the beginning and end that we haven't included, and the entire video is about 12 minutes. Have you seen that before? 

MR CLARK:  Yes. 

MS EASTMAN:  I just want to do this. The final. Looking at that incident and your table, if you look at the entry for 7 March 2019   

MR CLARK:  Yes. 

MS EASTMAN:    that was the entirety of the incident in the summary; you agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  You will have seen that the only interaction between the police officer and Kaleb was at the beginning to coax Kaleb down the stairs and back to his dad. 

MR CLARK:  Of that recording just played, correct. 

MS EASTMAN:  There's nothing else to indicate that the police officer made any attempt to speak to Kaleb that you could see on that video? 

MR CLARK:  Well, he did speak to Kaleb encouraging him to come down the stairs. 

MS EASTMAN:  Yes, but other than that. 

MR CLARK:  But the child was nonresponsive. 

MS EASTMAN:  When you say ‘the child’, do you know how old Kaleb was? 

MR CLARK:  18. 

MS EASTMAN:  So he wasn't a child? 

MR CLARK:  Correct. 

MS EASTMAN:  But his presentation, one might mistake him for a child. Would you agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  Perhaps on first view one would not assume that a young person wearing only a nappy would be someone over the age of 18? 

MR CLARK:  Yes. 

MS EASTMAN:  You agree that most of the conversation between the two people at the top of the stairs and the officer were about Kaleb and their   and I'm just summarising   their concern or wish to show the police officer the photographs that they had wanted to send to Child Safety. You agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  That the police officer engaged with the two [redacted] in a manner that sought to deescalate the situation in terms   in terms of tone and manner. 

MR CLARK:  Yes. 

MS EASTMAN:  Is that right? And you would expect the police officer to do that? 

MR CLARK:  Correct. 

MS EASTMAN:  You would expect, if the police officer was being asked to look at photographs that might indicate a concern about neglect, that that would be the police officer's responsibility to do that? 

MR CLARK:  Yes. 

MS EASTMAN:  The conversations around those photographs were all directed at giving them to Child Safety or having Child Safety come out and look at the photographs. 

MR CLARK:  Yes. 

MS EASTMAN:  That seems to be the exchange. Was there a responsibility for the police officer, based on that information, to report the matter to Child Safety as the police officer said in the course of that exchange? 

MR CLARK:  Yes, the officer needed to confirm that Child Safety were aware of that information. 

MS EASTMAN:  And that never happened? 

MR CLARK:  No, I'm aware that they did confirm that Child Safety had been there that day and had attended in relation to Jonathon. 

MS EASTMAN:  Were you here earlier today? 

MR CLARK:  I arrived whilst Dr Crawford was giving evidence. 

MS EASTMAN:  When Dr Crawford   and Commissioner Ryan asked some questions about this particular incident and referred to the agreed facts and asked Dr Crawford whether the police   Child Safety received the police notifications. She said no. 

MR CLARK:  I didn't say a police notification. I'd said that Child Safety were aware of the information. 

MS EASTMAN:  How do you know that Child Safety were aware of the information and what fact are you relying on? 

MR CLARK:  We've got their intake assessment where it identifies that they'd attended that day at that residence.

MS EASTMAN:  Earlier in the day they had. 

MR CLARK:  Yes. 

MS EASTMAN:  But I'm talking about after the police came. Did the police notify after the police were there? 

MR CLARK:  I can't say whether they passed on further information or not. 

MS EASTMAN:  They should have. They should have. 

MR CLARK:  What information were they providing that they   Child Safety didn't already have, would be the question. 

MS EASTMAN:  How do you know that? 

MR CLARK:  How do you know he didn't? That's a view   

MS EASTMAN:  How do you know the police officer had any knowledge that Child Safety had been, other than what the police officer was told? 

MR CLARK:  At the time on that video, they were relying on the   the father. I'm advised that we've confirmed that Child Safety had attended that residence, so   

MS EASTMAN:  But you accept, don't you, that the police did not take the step of notifying Child Safety in relation to the matters that the police officers attended to? 

MR CLARK:  Yes. 

MS EASTMAN:  In terms of the interaction with the father, there was an interaction. The father seemed to be very ready and willing to tell the police his side of the story. You agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  And his side of the story was, may I say, critical of the [redacted]. Do you agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  Accepting that the police were taking an approach of de-escalation, you'd agree, though, that at no point did the police ask any questions in relation to the matters that [redacted] had raised or express any concerns about the father's care of his children. You agree with that? 

MR CLARK:  Did they make any inquiries   sorry, is that what you   

MS EASTMAN:  Of the father. There was no putting allegations to the father based on what [redacted] had said? 

MR CLARK:  No, the primary purpose of our attendance was in relation to Kaleb being [redacted]. He was 18 years of age, and they returned him back to his father. 

MS EASTMAN:  And is it common for an 18 year old to have to be returned back to their father with the assistance of police? 

MR CLARK:  I wouldn't say it's common but we're talking about a person with a disability, and that's not uncommon that police get called to instances where we're requested to provide assistance so   

MS EASTMAN:  And at no point did the police say to Kaleb, ‘Would you like to return to your father?’. At no point did the police say to Kaleb, ‘Are you worried about something’ or, ‘You don't want to return to your father.’ At no point it did the police intervene and check that Kaleb wanted to return to the father when the father grabbed him at the bottom of the stairs and pulled him away. That didn't happen, did it? 

MR CLARK:  They certainly didn't ask any of those questions on the video footage. 

MS EASTMAN:  Can I put to you, if Kaleb had been a young person without disability in those circumstances, would you expect the police to have asked the young person if they wished to return to their father or to check on that young person before they were returned to their father? 

MR CLARK:  If they were 18 or if they were a child? 

MS EASTMAN:  If they were 18. 

MR CLARK:  They   yeah, I'd expect an 18 year old can make their own decisions about where they'd like to be. 

MS EASTMAN:  And the only reason that that did not occur for Kaleb is because of Kaleb's disability and presentation; would you agree with that? 

MR CLARK:  Yes. 

MS EASTMAN:  The last things I want to put to you is you've said at the beginning that you did not think that there was anything either at the time or on your subsequent review and up to today that required any improvement by the police. Does that remain your position? 

MR CLARK:  Yes, I think you'd framed that about policy and procedure. I don't think anything I've heard today would require a change in policy or procedure. 

MS EASTMAN:  Do you accept from the information that you have in the preparation of your evidence for this case study, that Kaleb and Jonathon experienced violence, abuse, neglect and a deprivation of their rights over the period that they were in their father's care from 2000 up to 27 May 2020? 

MR CLARK:  I don't think there's confirmed evidence of violence. 

MS EASTMAN:  Were you here earlier when you heard the Commissioners ask about what violence means? Were you here? 

MR CLARK:  We're talking physical violence? No, I wasn't. 

MS EASTMAN:  Alright. So, your understanding of violence is physical violence, is it? 

MR CLARK:  In that context, that's the way I was referring to it. 

MS EASTMAN:  Alright. Well, Commissioner Ryan might have a question for you, then. Secondly, do you accept that with respect to the incidents of violence, abuse, the neglect and deprivation of Kaleb and Jonathon's rights, that it was preventable? 

MS McMILLAN:  Well, I object. I don't know that this witness has agreed with all of those terms, for a start, so they should be asked properly in sequence. And so far as, what, the police are concerned? 

MS EASTMAN:  I think the question's fairly straightforward. You've read, haven't you, the indicative findings? 

MR CLARK:  Yes. 

MS EASTMAN:  And you will have seen that indicative finding 2 says that it's open to the Royal Commission to find that the violence, abuse, neglect and deprivation of rights experienced by Kaleb and Jonathon was preventable. You've seen that? 

MR CLARK:  Yes. 

MS EASTMAN:  You're able to answer that question, aren't you? 

MR CLARK:  Yes, I've read that. 

MS EASTMAN:  And you can answer that question? 

MR CLARK:  I don't know if I can.  Preventable.

MS EASTMAN:  What would have made it not   what would have made it inevitable that each of them, in the course of their life with their father, would make it inevitable that they would experience violence, abuse, neglect, or a deprivation of their rights? 

MR CLARK:  I'm not sure what you're asking. 

MS EASTMAN:  I'm asking you and I'm putting to you is what occurred to those boys was preventable. And you're equivocating on that, aren't you? You can't answer that. You don't know? 

MR CLARK:  Preventable   

MS EASTMAN:  Let me put this to you. There's nothing inherent about either of those two young men that made it inevitable that they should live with a life of violence, abuse, neglect or exploitation. Do you accept that? 

MR CLARK:  Yes. 

MS EASTMAN:  Second proposition, that if agencies are aware of risk factors that may cause or contribute to violence, abuse, neglect or deprivation of rights, then an awareness of those risk factors is an element of determining whether the inevitable is preventable? 

MR CLARK:  Yes. 

MS EASTMAN:  And police were aware of risk factors, were they not? 

MR CLARK:  Yes. 

MS EASTMAN:  You have extensive records in the QPRIME that give you a fairly long history of risk factors. You have, for example, Paul Barrett being charged and convicted of behaving in a disorderly manner and threatening towards his then partner when she was pregnant with Jonathon. You're aware of that, aren't you? 

MR CLARK:  Yes, 2002. 

MS EASTMAN:  So looking at all of the matters over a period of time, there was ample material to identify what the risks were to these two young people. Do you accept that? 

MR CLARK:  Yes. 

MS EASTMAN:  Right. So, come back to my proposition. On the basis that it wasn't inevitable and the risk factors were known, do you accept that the violence, abuse, neglect and deprivation of rights was preventable? 

MR CLARK:  I'll come back to again that every time police interacted with this family, either we've made a decision that there was no child harm, so no report was made, or where we held concerns, that was reported to the appropriate authority. It was then up to that authority to assess the child harm and the conditions that the children were in. So, their   their living conditions, by my standards, not the way I would live, but a professional agency made an assessment and were prepared to leave the children at that residence. So, I'm not sure I can   

MS EASTMAN:  So, that's Child Safety issue, not your   not police; is that right? 

MR CLARK:  Child Safety are the   

MS EASTMAN:  Child Safety. 

MR CLARK:    Are the experts in relation to making an assessment about the welfare and wellbeing of those children, and they've made determinations to either leave the children at the residence with the father as the carer or on occasion, as we've identified, they've removed those children. 

MS EASTMAN:  I want to put to you that there were, in the 10 interactions that police had with the family, opportunities for the police to take action to prevent the violence, abuse, neglect and deprivation of rights, and that's illustrated by the fact in 2010 when the police did act to remove the children. You'd agree with that? 

MR CLARK:  I'd agree that each and every time we identified child harm or had serious concerns about child harm, we reported it to the appropriate authority, which is the expectation of our officers. So, I do believe we acted appropriately on each and over occasion, and the 2010 is a very good example where the Child Protection Act and   was exercised and it led to that children being, by agreement, removed and an assessment conducted and then they were returned to that address. So, on each and every occasion, an assessment was being made by the department and then an outcome. So, I think the police did identify and report as required. 

MS EASTMAN:  I want to put to you that police should have done more to prevent the violence, abuse, neglect and deprivation of the rights of these two young people. Do you agree with that? 

MR CLARK:  I'd be interested to know exactly what you think we could have done more other than   

MS EASTMAN:  I'm asking the questions. I'm not answering them. 

MR CLARK:  Well   

MS EASTMAN:  If you are not able to identify what more should have been done, that's a question for you, is it not, not for me? 


MS EASTMAN:  If you have something you'd like to say   it's quite distracting to both the witness and for I to have a running commentary from behind.

COMMISSIONER McEWIN:  If you could keep that at a minimum so that it doesn't distract. That would be appreciated. Could you answer the question or do you want Ms Eastman to repeat? 

MR CLARK:  Please, I'd like the question repeated, thanks. 

MS EASTMAN:  Can I get the transcript and I'll read it back directly   no, we don't have it. What I put to you is the police should have taken action to prevent the violence, abuse, neglect and the deprivation of the rights experienced by these two young men. You asked me the question, ‘What do I mean by that?’ I said to you, ‘I'm the one asking the questions; you're answering’. 

MR CLARK:  So what I   

MS EASTMAN:  And I said to you, ‘If you can't identify what should have been done, then I'm interested to know why’. So, that's where we got up to. 

MR CLARK:  So, I'm satisfied that the police did take the appropriate action when they identified serious concerns about child harm and reported it to the authorities as we're required to do on   by   

MS EASTMAN:  And your degree of satisfaction is based on a review of the records and a reliance on the table that you've prepared for those desktop reviews that you did; is that right? 

MR CLARK:  Correct. 

MS EASTMAN:  Thank you. Those are my questions. Thank you, Commissioners.

COMMISSIONER McEWIN:  Thank you, Ms Eastman. Mr Clark, I'll ask my colleagues whether they have any questions. Commissioner Mason. 

COMMISSIONER MASON:  Thank you for your evidence today, Mr Clark. I have been asking each witness today about their understanding of the phrase, ‘Nothing about us without us’. Are you aware of that phrase? 

MR CLARK:  I haven't heard it but I understand the context or the concept. 

COMMISSIONER MASON:  Can you explain what your understanding is of that phrase in context, in relation to the work that you do? 

MR CLARK:  Yes, so that the young people and the families should have a voice in the decision making in relation to themselves that would impact on them. 

COMMISSIONER MASON:  And we're specifically talking about which members of the community, when we ise that phrase, ‘Nothing about us without us’? 

MR CLARK:  I don't know about specific members of the community. I'd expect that it refers to any party that we're making decisions about, that they should have a voice in that process. 

COMMISSIONER MASON:  I feel like I need to rely on the Chair because the Chair has much more of a deep understanding about  ‘Nothing about us without us’, but it specifically relates to people with disabilities, particularly in service providers making decisions about members of their disability community, that members of the disability community should be a part of those decisions or involved, supporting, providing their subject matter expertise in relation to a person with disabilities. 

So, I was interested in your response around vulnerable person, children who are vulnerable, and there's no reference in there to do with disability. That would be an oversight in relation to the particular circumstances and issues around disability and, in this case, nonverbal children with intellectual disabilities, that a kind of a catch all overarching definition or practice definition that's not specific to disability, then there's a lack of understanding. 

So, is that something that the police could look at in relation to providing members of Queensland Police with more insight and understanding around disability, but particularly those with intellectual disability who may be nonverbal? 

MR CLARK:  Yeah, I think that's a very valid point. So, in the last few years in particular, we have gone through significant reviews, and recommendations have been made in relation to our response to victims and vulnerable people, and I understand that disability is not necessarily either of those. But as part of that we are doing a lot of work with our officers around providing a trauma informed response. So, that's understanding the needs of the individual rather than relying on a system, that actual response is focused on the person, versus what we would like as an outcome. 

So, there is multiple different training products, both face to face and online learning, that we are producing and providing to our officers, so in relation to domestic and family violence, sexual violence, child protection concerns, but all of them have an underlying theme around how to identify and respond to vulnerability and provide that more focused response for those people. 

We've also recently established our Disability and Elder Abuse Unit. So, that's in our Vulnerable Persons Command, our Domestic and Family Violence and Vulnerable Persons Command to be precise. So we recognise that that is a specific group we need to provide more focus on, and that is part of our work, is that we will be looking at our response around disabilities and their   their key thing at the moment is that we're working on about our referral processes and how we can link it back into the NDIA for people with disabilities that we think or would identify with us that they need support. 

So, it's in its infancy I suppose, but we are certainly well aware of it and doing a lot of work to educate our workforce about how to provide a more trauma informed response. 

COMMISSIONER MASON:  When was that unit established? 

MR CLARK:  I don't know exactly when, but it's certainly within the recent past. I would say within the last 12 months, it's been stood up. 

COMMISSIONER MASON:  And are they   you may not know, but they should be liaising with organisations, disability organisations here in Queensland, people who are subject matter experts and across a range of disabilities as well, which would be really critical. And I guess the last question I have is around the term ‘intersectionality’. What's your understanding of that term, ‘intersectionality’ in relation to disability? 

MR CLARK:  I don't have a clear definition or understanding of what   


MR CLARK:    is being referred to. 

COMMISSIONER MASON:  Yep. That's in relation to people with disabilities, but they also come with a   a range of backgrounds. So, you have an Aboriginal person with disability and there is a   a diversity of expression and of life and living because they are both a person with disability and they are First Nations. So, it's not   using a public service term   looking at people in silos; it's looking at a greater diversity. 

And so with children, obviously, there's more complexities with that. But critical that the disability community are providing their advice and guidance and ongoing guidance and advice   advice around improvement and continual improvement, I would say, because of the work that the police do, and its contact with community. 

MR CLARK:  Yeah. I think that's a really good point around siloing. So, we look at   as I have a responsibility for a number of different tertiary responses, so sexual violence, child protection, but we   the intersections   and that's a good terminology in relation to the tertiary response to mental health, domestic and family violence, drugs, they   it's a really important fact that we are very aware of, and we are spending a lot of time and effort to ensure that we do engage and that we are working together in those different streams within the service to provide that holistic coordinated response. 

Because I accept that in the past we responded to domestic and family violence, but perhaps we didn't respond to the mental health issues. Or we responded to the child protection but perhaps we didn't consider the domestic and family violence because they were different tertiary responses. But we are heavily engaged, now, working together, and it's in the last two years in particular, to make sure that we are getting better and better at linking all of our services and responses together.

COMMISSIONER MASON:  Thank you very much. 

MR CLARK:  Could I just go back to one other point too? 


MR CLARK:  So we spoke about education and training in relation to disability. There's a piece of work in my group, so I got the Child Protection Offender Register within my area and that's where we manage the child sex offenders, I've got a forensic   forensic psychology team that sit within that register. So, for the last 18 months, they've been doing a lot of work and a dedicated project with Griffith University in relation to Autism. 

We're finding out some really, really interesting information and research in relation Autism in particular for that group of offenders and what means. We're identifying that a lot of these offenders actually are   have Autism but have never been identified. So, our response is now changing to those people so that rather than treating them   because their behaviour may have been seen as high risk or high concern; in fact, it was Autism. So, we're now working in with Autism Queensland and with other services to provide the support supports to those people and withdrawing the police response, as such, so, you know, we're   and   and with that we're also identifying  

COMMISSIONER McEWIN:  Mr Clark, sorry to interrupt. That's a very detailed response. Perhaps you could provide that more detail in writing. I'm conscious of time. 

MR CLARK:  Sorry.

COMMISSIONER McEWIN:  We've been here for quite some time, but I would be grateful if you could provide more detailed information and I'd like to give Commissioner Ryan an opportunity, if you have any questions. 

COMMISSIONER RYAN:  I do. First of all, did you hear the earlier evidence about these boys being subjected to living in a room that was locked, slipping in their own faeces, being bathed by their father in cold water and being fed raw meat?  Does that not suggest to you that these boys were subjected to violence? 

MR CLARK:  I wasn't aware of any of those things, other than the comment about being locked a room where, in the police report, it referred to the doorhandles being removed. So, I had not heard   I'd seen the photos post the death of the father in relation to the conditions within the house, but I certainly was not aware of any material about how they were being bathed, slipping, food, et cetera. 

COMMISSIONER RYAN:  But you are aware of that now, aren't you? 

MR CLARK:  Up until you mentioning it to me, I had not seen any   I had not read the other departments' reports, other than what was in the indicative findings, so   sorry, the statement of facts. So   

COMMISSIONER RYAN:  I believe in the agreed statement of facts you'd agree that there's incidents of violence that these boys have been subjected to. The police might not have seen it, but they've clearly been subjected to violence. Would you agree? 

MR CLARK:  I'll accept that, yes. 

COMMISSIONER RYAN:  Okay. Who was the appropriate   why do you think the informants that contacted you contacted police on the weekend of 19 January 2015? Why do you think those people went to Crime Stoppers to report that? 

MR CLARK:  That's   I couldn't answer that, but it's one of the many very publicly known means to make reports to police, but it's also an anonymous reporting process. So, it   it provides   they may have been aware that it provided anonymity. 

COMMISSIONER RYAN:  You think there's a chance they went to Crime Stoppers because they thought a crime had happened? 

MR CLARK:  Possibly. 

COMMISSIONER RYAN:  So who is the appropriate authority to investigate crimes? 

MR CLARK:  Well, that's the police. 

COMMISSIONER RYAN:  Okay. You would agree that among the things police were told is that these two boys were left unsupervised, possibly for days on end, in temperatures of in excess of 37 degrees, and it doesn't appear they had anybody to give them water. You'd agree that that would be a very dangerous position for young boys to be left in who can't get themselves a drink of water   get water or hydrate themselves, wouldn't you? 


COMMISSIONER RYAN:  Do you think   there doesn't appear to be any evidence that when the police spoke to Mr Barrett on that evening that they even inquired as to whether he had been leaving the children for long periods of time, during a heat wave   I took the time to actually check what the weather was like in Brisbane around that time, and there was a heatwave around that time. Do you think the police should have investigated as to whether the kids were being   young men were being left for days on end without access to water in a locked tent? 

MR CLARK:  There's no evidence to say that they did or they didn't make those inquiries. 

COMMISSIONER RYAN:  No, but you'd agree that that's an allegation of a crime, isn't it? 

MR CLARK:  Yes. 

COMMISSIONER RYAN:  So don't the police have an obligation to investigate it? 

MR CLARK:  Yes. 

COMMISSIONER RYAN:  The point that I make to you is, without going into a lot of detail, Mr Clark, or Superintendent Clark, there seems to be numerous opportunities   the police had the opportunity to expose themselves to the potential that a crime had taken place. In fact, one we've seen with our own eyes today, where the police were   somebody was attempting to show the police some photographs on a   on a phone, and it looked to me that the police did not want to see those photographs. 

They said, ‘Take them to Child Protection Services’ and these people appeared to be saying to the police, ‘We want to report this danger to you’ and the police said   it almost looked to me like they didn't want to see them. From memory, I don't even think they touched the camera   they touched the phone for very long. They just said show it to someone else.

COMMISSIONER McEWIN:  Commissioner Ryan, can you get to the questioning please   .

COMMISSIONER RYAN:  The question that I'm asking   the context is somebody appeared to be reporting what could have been a crime. It looked to me that the police didn't think it was a crime and wanted to refer it to Child Services. Do you agree? 

MR CLARK:  I think the   the overarching reason the police were there were for protection concerns in relation to Kaleb. So, I think that the response was   was appropriate when you are considering that it was about the protection of the young people that they were there for. 

COMMISSIONER RYAN:  Superintendent Clark, I accept they might have been there for another reason, but I think I saw with my own two eyes two people trying to report something to police, and they appeared not to look at it. Do you agree they could have been trying to report a crime which police might have needed to investigate and didn't? 

MR CLARK:  From my recollection of the video, they said this is the conditions of the house. 


MR CLARK:  Is that what we're referring to? 

COMMISSIONER RYAN:  And we've discussed section 364 of the Queensland Criminal Code. 

MR CLARK:  Yes. 

COMMISSIONER RYAN:  So they could have been trying to report a crime, couldn't they? 

MR CLARK:  They could have been. 

COMMISSIONER RYAN:  Why do you think the police were not interested? 

MS McMILLAN:  With respect, this line of questioning is not fair. This Detective Superintendent was not there at the time. 

COMMISSIONER RYAN:  I'll rephrase the question. Why do you think the police did not wish to look at the photographs which could have revealed a crime? 

MS McMILLAN:  Again, that's a value judgment and I object.

COMMISSIONER McEWIN:  Do you want to withdraw the question?


COMMISSIONER McEWIN:  Do you want an answer? 


COMMISSIONER McEWIN:  Do you want to re frame and keep it to the point that the    

COMMISSIONER RYAN:  The point I'm making is that two people appeared to want to report something to the police and they appeared to assume that it was another department's job, not theirs. 

MR CLARK:  Yes, so the view taken was that it was around the concerns for protection of the children and that the information should be conveyed to Child Safety. 

COMMISSIONER RYAN:  Do you agree that you've referred to other laws and have had referenced to you a number of laws that relate to the protection of children which are considered to be crimes? 

MR CLARK:  Yes. 

COMMISSIONER RYAN:  Do you agree  

COMMISSIONER McEWIN:  Commissioner, I think we've  

COMMISSIONER RYAN:  I have a single   

COMMISSIONER McEWIN:  I think I'm going to have to come back   

COMMISSIONER RYAN:  Do you remember back in the time when domestic violence   people used to think domestic violence wasn't a crime? Do you think the police might be operating on the basis that the protection of children in these circumstances where there are people with disabilities, that this isn't a crime? 


MS McMILLAN:  With respect, again, this is really unfair. I mean, the situation with domestic violence, for instance, is a very complex one. It's not appropriate in this forum in this way to be taking it up with this witness.

COMMISSIONER McEWIN:  Commissioner, could you consider that your final question to relate it back to the point of the video of what you observed and ask the question relating to facts. 

COMMISSIONER RYAN:  Do you think there's something police in Queensland need to understand about child protection matters being a crime? 

MR CLARK:  No, I don't. And it's a very complex field and it's very easy to say that perhaps we should be taking action against the father, but when we look at the Child Protection Act and you consider that what's in the best interests of the child, perhaps arresting the father is not in the best interests of the child, that perhaps working with Child Safety and working with that family to provide appropriate support is the better answer. It's not each and every time that we need to be taking somebody before the court for a crime if there is a better response. 

COMMISSIONER RYAN:  The words speak for themselves, Detective Clark. Thank you, Mr Chair. 

MS McMILLAN:  I object to that commentary.

MR CLARK:  I'd just like to also identify in relation to cruelty to children and that offence, the point that   even though there may have been concerns identified, if we were going to proceed before a court for that offence, we would need expert evidence that that was, indeed, neglect. So, our experts actually are Child Safety. So, before we could proceed in that instance we would be going to Child Safety and saying are you satisfied that that is criminal neglect? So, referring to the offence of cruelty to children, it exists, but, in all honestly, we   it is more of a child protection concern.

COMMISSIONER McEWIN:  Thank you, Commissioner Ryan. The parties with leave to appear, any questions or comments? 

MS McMILLAN:  Yes, thank you. Detective Superintendent, that video that you were shown, is it an excerpt of the video that you were shown here today? 

MR CLARK:  Yes, there is a full video showing the engagement with the father prior. In particular, he made comments in relation to the [redacted] and the nature of that relationship. 

MS McMILLAN:  And how long does that video go for approximately? 

MR CLARK:  Nine minutes, maybe, something like that. 

MS EASTMAN:  I object to this. I did qualify with the witness that it was an extract of the video and I said I think it went for about 12 minutes. So, I've already dealt with this. 

MS McMILLAN:  Well, with respect   

MS EASTMAN:  With respect, it's not re examination. 

MS McMILLAN:  Accepting re examination doesn’t apply and to call it back into some perspective, it is an excerpt of at least nine minutes of video. 

MR CLARK:  Yes. 

MS McMILLAN:  Right. And did you raise your scenario in relation to the totality of the video? 

MS EASTMAN:  No. I object to that question. I'm not quite sure what my learned friend means by ‘the scenario’. I asked the Detective Superintendent particular questions and he answered them. I did not ask him about what his view of a scenario was.

COMMISSIONER McEWIN:  Ms McMillan, you're talking about the video and the length of it? 

MS McMILLAN:  Yes. Yes.

COMMISSIONER McEWIN:  And you're wanting to say whether the totality is   

MS McMILLAN:  Yes. And also, I will require it to be tendered, that is, the entirety of it, but I'll take that up after the Detective Superintendent has gone. Now, can I also ask you, the TAO that's referred to   and that was in that call out of 2010, 3 March   TAO is, is it correct, a temporary assessment order? 

MR CLARK:  Correct. 

MS McMILLAN:  Under the Child Protection Act? 

MR CLARK:  Yes. 

MS McMILLAN:  And do you understand, what's the purpose of those? 

MR CLARK:  Where we believe the child is at risk of harm, we can have that child removed, placed in the temporary care of the department whilst an assessment is conducted. 

MS McMILLAN:  Thank you. And in terms of - you were asked about the QFCC report and you say you provided information on policy and procedure. Was that what you were asked to do? 

MR CLARK:  Correct. 

MS McMILLAN:  Yes. Thank you. I've got nothing further. Might this witness be excused? 




COMMISSIONER McEWIN:  I appreciate we've gone well over time.  So thank you, Mr Clark, for your extensive contribution to our work. You may be excused and I'll now check with Counsel Assisting, we've gone well over and I apologise to everyone that we've gone well over what we planned for lunch so we should probably adjourn for a late lunch. 

MS EASTMAN:  Yes, until 2.30.

COMMISSIONER McEWIN:  Alright. So 45 minutes. Alright. We will adjourn until 2.30. Thank you. 





MS EASTMAN:  Thank you, Commissioner. Our next witness is Ms Michelle Bullen from the Department of Seniors, Disability Services and Aboriginal and Torres Strait Islander Partnerships. And Ms Bullen is taking an affirmation.


COMMISSIONER McEWIN:  Thank you, Ms Bullen, for coming to the Royal Commission. We appreciate your forthcoming contribution as well as for the material that you provided us. We're grateful for that. I'm Commissioner McEwin. This is Commissioner Mason and Commissioner Ryan. The associate, who is just to your right, will administer the affirmation. Thank you. 

THE ASSOCIATE:  I will read you the affirmation. At the end, please say yes or I do. Do you solemnly and sincerely declare and affirm that the evidence which you shall give will be the truth, the whole truth and nothing but the truth? 



COMMISSIONER McEWIN:  Ms Eastman will now ask you some questions. 


MS EASTMAN:  Thank you. Can I confirm you are Michelle Bullen? 


MS EASTMAN:  You hold the role of Executive Director, Inclusion, Programs and Safeguards   sorry, I'll withdraw that.  That's the old title; is that right? 


MS EASTMAN:  And the new title is now Executive Director, Inclusion, Programs and Strategy; is that right? 


MS EASTMAN:  And that's office within the Department of Seniors, Disability Services and Aboriginal and Torres Strait Islander Partnerships. 


MS EASTMAN:  I'm sure there is an acronym for that, but I might just refer to it as the department, if that's convenient. 

MS BULLEN:  Yes, thank you. 

MS EASTMAN:  You've previously given evidence to the Royal Commission at Public hearing 31 concerning a vision for an inclusive Australia. 


MS EASTMAN:  And I think you gave evidence on that occasion about Queensland's actions under Australia's Disability Strategy. 


MS EASTMAN:  Today, though, you've prepared a statement for this case study. Have you had an opportunity to read through the statement? 


MS EASTMAN:  Are there any corrections that you wish to make to the statement at all? 


MS EASTMAN:  And are its contents true and correct? 


MS EASTMAN:  And I think the date is 5 May this year; is that right? 


MS EASTMAN:  So, your statement acknowledges that you have read the agreed facts. 


MS EASTMAN:  And you say at paragraph 14 of the statement that having reviewed the proposed agreed facts, reviewed the document, you confirm that the matters in the agreed facts align with the documents that you've reviewed; is that right? 


MS EASTMAN:  So you don't take any issue with the content of the agreed facts to the extent that they're relevant to your department? 

MS BULLEN:  That's correct. 

MS EASTMAN:  Your statement sets out from paragraphs 16 to 29 the role of the department in the transition to the NDIS from Queensland Disability Services to the Commonwealth arrangements under the NDIA. And you also, in those paragraphs, speak to Kaleb's transition from May 2016 and Jonathon's transition also which commenced in May 2016 but, as you acknowledge, did not occur before his father's death. 


MS EASTMAN:  One question I want to ask you about the transition progress is paragraph 28. Can I ask you to turn to paragraph 28?


MS EASTMAN:  This is in the context of supporting Jonathon to make the   I'll use the shorthand expression   the applications necessary to become an NDIA participant; is that right? 


MS EASTMAN:  And you say in the statement that:

    ‘The Department of Education provided some information to the NDIA.’

Is that right? 

MS BULLEN:  The Department of Education, yes. There was a number of departments, yes. 

MS EASTMAN:  You've told the Royal Commission in paragraph 28 that your department unsuccessfully attempted to contact Mr Barrett on seven occasions between October 2018 and March 2019 to offer assistance regarding the transition of Jonathon to the NDIS. 


MS EASTMAN:  The identification of the seven occasions is based on your review of the department's records. 


MS EASTMAN:  Is that right? 


MS EASTMAN:  And is the nature of the attempts to contact the father all either by phone or email? 

MS BULLEN:  Yes, that's my recollection. I've read those documents, yes. 

MS EASTMAN:  There's nothing in the records to indicate the attempts to contact the father were done at any time in person? 

MS BULLEN:  Not in these records, no. 

MS EASTMAN:  And not done through, for example, the school in terms of support through the school processes? 

MS BULLEN:  So, the records I've got relate to the actions that our staff took. I don't have visibility over the actions the school might have taken. The transition process, our department facilitated that for the Queensland Government. The Department of Education supplied theirs directly to the NDIA themselves, whereas we provided our data and Queensland Health's data and other departmental data on behalf of the government. So, the Education dataset was separate. 

MS EASTMAN:  Was there something that triggered the department   your department making attempts to contact the father in that period October 2018 to 2019? 

MS BULLEN:  Yes. So, during transition   and it was before my time in the department, but it's been explained to me as a process and there were certainly exchanges of datasets between   

MS EASTMAN:  Could I just   I know I'm going very quickly. But just slow down please. Thank you.

MS BULLEN:  Sorry. The process was, our department and the NDIA regularly exchanged datasets. We provided lists of names, essentially, initially. They then provided us back, if you like, status updates on those clients so we could see where there were in the process of transitioning. So, we had a number of statuses at different stages in the process. And our regional offices, as transition was occurring on a regional basis, their role was then to review the records we got back to show the clients who hadn't yet completed transition and to follow up as much as possible with those people directly to assist them if we could. 

MS EASTMAN:  Was your department aware that Jonathon's application had in, in effect, been cancelled? 

MS BULLEN:  There was a number of statuses that they   yes, and they certainly refer to that status of access not been met at different parts of the reports, the database. 

MS EASTMAN:  You've had an opportunity to look at the agreed facts, and if you look at the facts relevant to the period October 2018 to March 2019, which is paragraphs 251 to 297, can I just ask you if you've read that? 

MS BULLEN:  I have read them, yes. 

MS EASTMAN:  And if you look at that period of time, one can't explain the circumstances of noncontact by the father or the young people being away from their home or out of contact. You'd agree with that? 

MS BULLEN:  In 251 to two five   

MS EASTMAN:  251 to 297.

MS BULLEN:  297. 

MS EASTMAN:  So, what I want to put to you is there's quite a lot of activity going on and interaction with Child Safety and Education. There was a safety plan put in place at that time and there had been a notification to Child Safety on 6 March 2019 where the NDIS issues had been discussed. That's agreed fact 292. So, you've read those facts, haven't you? 

MS BULLEN:  I have read them. I don't know them inside out. 

MS EASTMAN:  I'm not asking you to recall the detail. 


MS EASTMAN:  But I'm just putting to you that during the period of the seven attempts, it's not that the family was away and that what we can see from the facts is that there was quite a lot of interaction with government   different government agencies at the time. 

MS BULLEN:  Mm hmm. 

MS EASTMAN:  My question is: at what point does it take for unsuccessful attempts to contact before the department might do something different than just try to contact by phone or email? 

MS BULLEN:  In this particular case, there isn't any evidence that we did anything other than that, and we had   from the notes, we had numbers that weren't correct or were no longer current phone numbers that we were trying. And I do   have read notes where we left messages for the father to call back. But in terms of this particular case, there's nothing in the records that suggests we did anything different. 

I am aware during transition that there were other cases where   an example that was described to me was our staff were asked to stop stalking people because they felt that we'd been harassing them in our attempts to assist them and to follow them when we saw them in the street. In fact, I was told someone had followed someone in the street and said can we help you, and they basically said, no, leave us alone. So, I am aware that our regional staff did a lot, as much as they could, but, obviously, it wasn't the same in every case, and it would probably depend on the extent to which they had a relationship previously with the family concerned.  And in the smaller regional areas, there was a close connection, but in this particular case, I can't see that we did that. 

MS EASTMAN:  There was no attempt, according to your statement, for the department to contact Jonathon directly? 

MS BULLEN:  No, not that I'm aware of. 

MS EASTMAN:  Was there any reason why there was no attempt to contact him generally? 

MS BULLEN:  Not at that time, and I'm not aware of any reason. 

MS EASTMAN:  And if there had been unsuccessful attempts to contact the father, it would have been open to the department to make some type of contact directly with the young person? 

MS BULLEN:  At that time, he was still a child. Possibly, yes. 

MS EASTMAN:  Alright. So, next matter I want to ask you about is the QFCC review report. 


MS EASTMAN:  And you've addressed this in your statement from paragraph 30 onwards. You told the Royal Commission that the Department cooperated fully with the QFCC review by providing documents, data and confidential information. So, what were the circumstances in which you provided confidential information to the QFCC? We've heard some evidence yesterday about the nature of the information that it could obtain. 

MS BULLEN:  So, the information that we provided was provided in documents that we supplied, and it included an outline of the policies and procedures and the things that they specifically asked for and a copy of those documents. Some of them were publicly available documents. Some of them weren't. And then we also provided an extract of   of the transition arrangements and the role that our department played.

MS EASTMAN:  Is it the transition arrangements particular to the two young people that constituted the confidential information? 

MS BULLEN:  No, just generally the process that was applied at the time. 

MS EASTMAN:  So, are you able to identify what the nature of the confidential information was? 

MS BULLEN:  It was confidential in that it wasn't information   excuse me   that was in the public domain. 

MS EASTMAN:  Take a glass of water. 

MS BULLEN:  Yes, sorry. It wasn't individual records relating to those children. 

MS EASTMAN:  Right. The department itself did not undertake any departmental review, and the reason, you say, is because the department had stopped providing services to the family; is that right? 

MS BULLEN:  That certainly would have been one of the reasons at the time. 

MS EASTMAN:  And on 30 March 2021, the Attorney General provided a copy of the report to the department or to your Minister? 

MS BULLEN:  To the Minister. 

MS EASTMAN:  And then that came to the department. 


MS EASTMAN:  You say in paragraph 33 that you were aware that the report was provided to the Department of Child Safety, Department of Education, Department of Disability Services and Premier in Queensland. How is it that you know which ministers or departments received the report? 

MS BULLEN:  I'm just referring to the letter. Yeah, I can't honestly say. From the letter, it's not apparent, the covering letter. We certainly had a role in liaising with other agencies around their   the actions that they could take in relation to implementing the findings of that report. So, we may have discussed it with them. We did invite the Queensland Family and Child Commission to present at a couple of government forums in that regard, and it may be in those discussions. 

MS EASTMAN:  Do you know if the report was provided to the police, the Department of Housing? Do you know that? 

MS BULLEN:  I don't know that, no. 

MS EASTMAN:  Now, you say then:

‘To ensure agencies including Commonwealth agencies were aware of the QFCC's report findings, your department arranged for the QFCC to present its findings to two meetings, one on 15 February 2022 and one on 24 March 2022.’

See that? 


MS EASTMAN:  That's about 11 and almost 12 months, respectively, from when you received the report. Given the nature of the findings in your report, why did it take so long to present those findings to relevant Commonwealth agencies? 

MS BULLEN:  I don't   I'm not aware of any specific reason other than those forums are quarterly   yeah, quarterly, I think, at the time, and there's always   you know, the process of getting items on the agenda, I guess, is one that requires scheduling. I don't   I'm not aware of any reason other than that in terms of the timing and availability of people to come and present.

MS EASTMAN:  Right. Thank you. Those are my questions.

COMMISSIONER McEWIN:  Thank you, Ms Eastman. Ms Bullen, I'll ask my colleagues now if they have any questions. Commissioner Ryan? 

COMMISSIONER RYAN:  Only one. There's a reference on item   it's at paragraph 43 where you've said that:

    ‘They established a new disability advocacy funding program which commenced on 1 January...’


COMMISSIONER RYAN:  How extensive is that? Is there many people involved in that or budget or something to give us some idea of the size. 

MS BULLEN:  Yes, I can do that. So, the current budget is $4 million per annum. Currently we fund 11   11, let me just quickly count   12 individual services, non government advocacy organisations, to provide advocacy services to people with disability and their families. As a result of the QFCC review we took the opportunity to review the arrangements we had in place for funding advocacy organisations, and as part of that review, we effectively reallocated the funding to make sure that we had State wide coverage and a advocacy organisations in each of the NDIS regions across Queensland.  We allocated that money on a population basis, basically, based on the size of the regions. We also specifically put aside money and allocated funding for an advocacy organisation to focus specifically on children and young people with disability, and our current provider of that service is Queensland Advocacy Inc. 

COMMISSIONER RYAN:  Those services intended for a wider function than simply helping people into the NDIS? 

MS BULLEN:  Absolutely, yes. 

COMMISSIONER RYAN:  So, if I was accessing housing, for example, I could use   or education if had I a problem. 

MS BULLEN:  Yes, any service, whether it's government or non government, if they need the assistance of an advocacy organisation. 

COMMISSIONER RYAN:  Thank you. Thank you, Mr Chair.

COMMISSIONER McEWIN:  Commissioner Mason. 

COMMISSIONER MASON:  Thank you, Chair, just one question. Were you able to hear the evidence previously? Yes? The previous witness   

MS BULLEN:  I have listened to most of it, yes.

COMMISSIONER MASON:  Just in summary all of the witnesses today indicated areas for improvement around policies, procedures and practices around disability, and we're particularly looking at young people, children with intellectual disability, nonverbal. Is that an area that your department could really provide leadership in terms of improving knowledge and understanding of practices in those agencies and others that may interact with children, young people with disabilities? 

MS BULLEN:  Absolutely. Our department does have a lead role as   as the department for among other things, people with disability. We have, as part of that role   as we mentioned earlier, we have released the   Queensland's new disability plan, together a better Queensland. We developed that   that document to implement effectively Australia's Disability Strategy, and we did that in collaboration with people with disability, including or facilitated by Queenslanders With Disability Network. 

Under the   under the current legislative regime, in Queensland, the Disability Services Act, requires all government departments to have a Disability Service Plan, so the actions across government that implement, effectively, our State plan and the National Strategy now are delivered through departments' Disability Service Plans. Our department has identified a number of initiatives, including training   training resources and materials to support other government departments working with people with disability. 

We also help other government departments where they need advice. We've got the Queensland Disability Advisory Council is a Ministerial Advisory Council that provides advice specifically to government on issues relating or impacting on people with disability. And that Council is largely made up of members of people with disability. And so we can facilitate if government departments seek   need information and advice, they can do it through that forum. I think   does that answer your question? 

COMMISSIONER MASON:  Yes. What struck me was   

MS BULLEN:  Sorry. 

COMMISSIONER MASON:    as leaders in their departments, the acculturation of disability and best practice wasn't front of mind. So, yeah, really hope that as your agency takes the lead, that there's not just a one way flow of information but there's a way of monitoring and checking that best practice actually has been acculturated in these agencies.

MS BULLEN:  Absolutely. And the disability   the new State Disability Plan, which I do have a copy of here, we're treating that as, effectively a, call to action. So, not just government but non government organisations as well to step up and play their part in creating a truly inclusive Queensland, and that is our hope. We will also be reporting on progress and the Australia's Disability Strategy Outcomes Framework will be a good starting point for measuring how outcomes are being achieved. 

Our   the committee, the working group of people with disability who advised us in the development of this   this new plan were very clear that the things that they   we call them building blocks, but the fundamental basics, if you like, that need to be in place to really drive that change in culture is   there are four, I guess, four elements to it. One is co design and we refer to co design but what we really mean, as I heard you mention earlier in the hearings, nothing about us without us. And that is really what we're about, having people with disability at the table when decisions are being made. So, I'm flicking through trying to find the right section. 

COMMISSIONER McEWIN:  Ms Bullen, it might be more helpful if you provide that in writing or it's certainly somewhere  

MS BULLEN:  Yes, we can do that.

COMMISSIONER McEWIN:    in the materials, and we can have it be provided. I'm conscious of time. Did you want to add to your answer? 

MS BULLEN:  No, that's fine. We're happy to provide it. It is on our website as well, but I will provide it. 


COMMISSIONER McEWIN:  Just one quick follow up question from what Commissioner Mason was asking. And Commissioner Mason has asked other witnesses about their understanding of human rights and, more broadly, such as   a term we use, ableism, intersectionality, dignity, et cetera. I'm not going to ask you what your view is, but I want to know what are the challenges in getting the public service to have a common understanding, common knowledge? What are the gaps and perhaps give me a few quick brief points on that. What are the challenges? 

MS BULLEN:  I think the starting point is awareness and understanding, and certainly for our department we have one of our mandatory training modules for all our new starters is a Disability Awareness online training module and we promote that to staff regularly and we encourage people to refresh their training. And I think part of understanding that people   people with disability, people from culturally and linguistically diverse backgrounds, First Nations people, are primarily people, first and foremost, and have the same rights to   human rights and dignity as anybody else. The Disability Services Act sets that out and that existed long before the Human Rights Act, that those human rights principles have been, I guess, front and centre of what we've been doing for a very long time now.

COMMISSIONER McEWIN:  Thank you. Thank you very much for your contribution. We appreciate the information you've given us. Parties with leave to appear. Ms McMillan? 

MS McMILLAN:  Commissioner, I had mentioned to Counsel Assisting earlier that Ms Bullen would like to give some evidence about the transition and how they worked with the service providers for the young men. What she proposed and we're happy to do is put that in writing, given, particularly, the time.

COMMISSIONER McEWIN:  That sounds very sensible, given the time constraints we seem to be under at the moment. So, thank you. Anything else? 

MS McMILLAN:  No, might the witness be excused. Thank you.

COMMISSIONER McEWIN:  Yes. Thank you again, Ms Bullen. You are excused. 


COMMISSIONER McEWIN:  Ms Eastman. I'm conscious of time. 

MS EASTMAN:  The next witness is Mr Tracey, and Ms Mahony will take his evidence. 


MS MAHONY:  Chair, Mr Tracey will be taking an oath.

COMMISSIONER McEWIN:  Thank you. Mr Tracey, thank you very much for coming to the Royal Commission. We very much appreciate your forthcoming evidence and for the information you've given us. I'm Commissioner McEwin. This is Commissioner Mason and Commissioner Ryan. The associate, who's just to your right, will read out the oath. Thank you. 

THE ASSOCIATE:  I will read you the oath.  At the end, please say yes or I do. Do you swear by almighty God that the evidence which you shall give will be the truth, the whole truth and nothing but the truth? 

MR TRACEY:  I do. 


COMMISSIONER McEWIN:  Ms Mahony, thank you. 


MS MAHONY:  Your name is Frank Tracey? 

MR TRACEY:  That's correct. 

MS MAHONY:  And you are the Health Service Chief of the Children's Health, Queensland Hospital and Health Service. 

MR TRACEY:  That's correct. 

MS MAHONY:  You provided a statement for this Royal Commission and it was signed on 9 May 2023. So, I think yesterday. 

MR TRACEY:  I have. That's correct.

MS MAHONY:  And I assume you read it before signing it. 

MR TRACEY:  Yes, I did. 

MS MAHONY:  And you were satisfied that it was true and correct? 

MR TRACEY:  I am. 

MS MAHONY:  Have you read it since signing it and is there anything you want to change in it? 

MR TRACEY:  No, I am satisfied with the statement as is, thank you. 

MS MAHONY:  I understand you have a copy of that statement in front of you. 

MR TRACEY:  I do. 

MS MAHONY:  In terms of what you relied upon, if I can just take to you paragraph 3 of your statement, you say that you've read and understood the proposed statement of agreed facts, the indicative findings and that you've also reviewed the health related source information referred to within those documents as they relate to Queensland Health. 

MR TRACEY:  Yes, I have. 

MS MAHONY:  In your statement, you referred to a number of documents and you've adopted the Royal Commission's numbering system? 


MS MAHONY:  So, for example, if I take you to paragraph 6 and 7, you will see there a footnote also at 6 and 7, and they refer to documents that you've read; is that right? 

MR TRACEY:  That's correct. 

MS MAHONY:  And so any document that appears as a footnote is a document you've accessed? 


MS MAHONY:  And you've read? 


MS MAHONY:  And you   there's nothing about what you've read that would suggest to you that the documents are not accurate reports of what was taken at that time? 

MR TRACEY:  That's correct. 

MS MAHONY:  Did you read or rely on anything else in preparing your statement? 

MR TRACEY:  So, really, the proceedings   a summary of the proceedings on a daily basis in terms of what was being discussed. 

MS MAHONY:  So you've been kept up to date as to what's been happening this week. 


MS MAHONY:  And you understand the core messages and themes that have been coming through in the evidence. 

MR TRACEY:  Yes, I do. 

MS MAHONY:  At paragraph 5 of your statement you refer to Young Person 1 and Young Person 2. 


MS MAHONY:  And you understand that Young Person 1 is referred to as Kaleb in these proceedings and Young Person 2 is referred to as Jonathon? 

MR TRACEY:  Yes, I do. 

MS MAHONY:  I want to take you to a couple of matters in your statement. The first one is the SCAN meetings that you refer to, which is at paragraph 5 of your statement. Specifically, the SCAN meetings that are described at paragraph   sub paragraph (e). You say at sub paragraph (e):

    ‘There was a meeting of SCAN on 3 December 2018 and that was regarding Jonathon, resulting from a notification by a member of the public in November 2018 and then referral by DCS.’

Being a reference to Child Services. 

MR TRACEY:  Correct. 


    ‘The SCAN determined to further review the matter on 14 January 2019 and a further meeting did occur on 14 January.’

MR TRACEY:  That's correct. 

MS MAHONY:  In terms of the agreed facts   and this is   you don't have a copy of the agreed facts in front of you, but I'll just read it out to you. Paragraph 272 refers to a SCAN meeting that was held on 8 November   I withdraw that. That there was a meeting that   I'll start again:

    ‘On 14 January 2019, CPA SCAN held a meeting relating to Jonathon's care. The Department of Child Safety informed participants it had completed its IA of the 8 November 2018 notification and determined it was unsubstantiated.’ 

Now, the meeting, though that is not referred in that, is the meeting of   I'll just get back to it   the meeting of 3 December 2018. And at that particular meeting   and this is at paragraph 263 of the agreed facts   the meeting documented:

    ‘Paul Barrett informed the Department of Child Safety he had broken up with his partner and he believes that she had made a vexatious complaint. Paul Barrett informed the Department of Child Safety he had a large network of friends, he has an advocate that used to help   used to work at the school and he also spoke about having a friend that helped him come and clean. And Kaleb and Jonathon's rooms at home too were completely bare. Paul Barrett had blown up mattresses.’ 

And at the CPA SCAN, this is at paragraph 264:

    ‘The Department of Education informed participants that it considered Paul Barrett may be minimising Jonathon's seizures, which may be worth following up. Queensland Health informed participants Jonathon was last seen for seizures in April 2018; however, he didn't attend in October 2018 and his next appointment is in April 2019.’

And so there was a health participant informing parties of relevant medical matters relating to Jonathon; correct? 

MR TRACEY:  Correct. 

MS MAHONY:  That meeting identified two factors that could, on one reading, present concerns as to neglect. Do you agree with that? Maybe I'll go through what those two factors are. 

MR TRACEY:  That would be helpful. Thank you. 

MS MAHONY:  The discussion about:

    ‘Kaleb and Jonathon's rooms at home too were completely bare.’ 

So, no furnishings. Young people in a completely bare room.  No furnishings, no bed, no covers. That may speak to neglect, mightn't it? 

MR TRACEY:  Yes, I agree. 

MS MAHONY:  The fact that the school expressed a concern that Paul Barrett may be minimising Jonathon's seizures, which may be worth following up, that is an expression of potential neglect, isn't it? 

MR TRACEY:  Would be a concern and it could be construed as neglect. 

MS MAHONY:  Part of the role of the SCAN was to take those concerns on board, wasn't it? 

MR TRACEY:  Correct. 

MS MAHONY:  And part of the role of SCAN was to follow up on concerns of potential, for example, neglect; correct? 

MR TRACEY:  Correct. 

MS MAHONY:  In fact, those medical issues should not have to wait until April 2019, after the next SCAN meeting, to be followed up; correct? 

MR TRACEY:  If those matters were deemed serious by the medical participants in the SCAN meeting, they would likely be referred back to the paediatric health services and followed up. 

MS MAHONY:  Yes. You'd agree, though, wouldn't you, that where Queensland Health say Jonathon has not been seen for seizures   sorry, was last seen for seizures in April 2018 and had not attended the next appointment, that is of itself a sufficient concern to follow it up before the next SCAN meeting, isn't it? 

MR TRACEY:  It may not be. It depends on the individual case and the nature of the seizures and the severity of those and how they impact on the child's life. I can't comment in detail about particular cases. 

MS MAHONY:  But you would not know that unless you followed it up; correct? 

MR TRACEY:  You may know it in the initial stages after doing the initial assessment and treatment, and the fact that he was due for another follow up would indicate that he needed to be assessed further in terms of his wellbeing. 

MS MAHONY:  - So it was sufficient to wait to see whether he would turn up in April 2019 for the purposes of the SCAN meeting. 

MR TRACEY:  That would indicate to me that there wasn't significant concern about his seizure activity. 

MS MAHONY:  My question is, though, for the purposes of SCAN, SCAN being a body set up specifically to protect against neglect; correct? 

MR TRACEY:  Correct. 

MS MAHONY:  The fact that a young person with a history of seizures, tonic clonic seizures, hospitalisation for seizures, it ought to   SCAN ought to have the medical representative follow up on the concern expressed by the Department of Education; correct? 

MR TRACEY:  That's a reasonable conclusion. 

MS MAHONY:  At the meeting on 14 January   and if I can take you to the agreed fact, I'll read that out. It's at 272:

    ‘The Department of Child Safety informed participants that the November notification seemed like quite a malicious notification. Paul Barrett managed the care of Kaleb and Jonathon quite well, and Child Safety Officer thought Paul Barrett was doing his “absolute best” and “loved Kaleb and Jonathon”.’

That is not the test to determine whether someone is being subject to neglect, is it? That someone loves them and they're doing their best. 

MR TRACEY:  Certainly not from a health perspective. 

MS MAHONY:  And as a health representative on SCAN, it was incumbent on that person to draw attention to what the appropriate focus of the SCAN meeting should be; correct? 

MR TRACEY:  That would be a reasonable assumption to make. 

MS MAHONY:  The SCAN meeting showed no records of any inquiries made into the medical matters in the follow up period; correct? 

MR TRACEY:  Correct. 

MS MAHONY:  And there was no focus at all in that follow up meeting on how Kaleb and Jonathon had travelled in that interim period; correct? 

MR TRACEY:  If that has not been recorded, I would just like to say, if I may, that the Health participation in the SCAN process is to provide expert advice and support to the process. So, if it's not recorded specifically in there, that wouldn't necessarily mean that those conversations have not taken place. 

MS MAHONY:  Is that a deficit in the process, if that is what is occurring? If that expertise and expert opinion for at least a moment in time reflecting on something serious enough to bring it to a SCAN is not being documented, do you agree that reflects a deficiency in the SCAN process? 

MR TRACEY:  I   I certainly agree that it's a distinct opportunity for improvement in that process. It would certainly facilitate that more integrated conversation and   

MS MAHONY:  And allow new members of SCAN to look back and be fully and properly informed as to what past SCAN participants had examined and views expressed.

MR TRACEY:  I think that's very reasonable. 

MS MAHONY:  Given that, is that something that you would look into following this hearing, in terms of making more robust those SCAN processes to ensure that type of information is captured and documented? 

MR TRACEY:  I would respond to that by saying yes, simply, and it would be a welcomed opportunity, anything that we can do to strengthen our process to support children who are in distress or in peril is a good thing to do. 

MS MAHONY:  In terms of the provision of clinical care to Kaleb and Jonathon, you address that at paragraph 7 of your statement? 


MS MAHONY:  And you say at that statement that, to the best of your knowledge, you believe that provision of clinical care to Kaleb and Jonathon was of a high quality. 


MS MAHONY:  So, when we're talking about clinical care, are we talking about the physical engagement and examination of the client, the patient? 

MR TRACEY:  Yes, that's what we're talking about. So, for example, if one of these, you know, young people or children turned up to our ED department or an outpatient appointment that we have been thorough and clear in our treatment and that that treatment would be followed up accordingly. 

MS MAHONY:  So that requires, as part of that clinical care process, carrying out appropriate investigations? 

MR TRACEY:  Absolutely. 

MS MAHONY:  Making appropriate diagnoses where available? 


MS MAHONY:  Following up with the patient, the client? 


MS MAHONY:  Developing relationships with the patient and, where they are a child or a young person or a person who's unable to advocate independently, a person who supports them in their life? 

MR TRACEY:  From a person centred care perspective, the focus is always on the child, the young person. However, in paediatric health care, the engagement with the family or the carer or agencies who are supporting that child or young person is critical in terms of their care and treatment. 

MS MAHONY:  And where does the   in that clinical care process, where, for example, there are concerns about the capacity of that carer to adequately or appropriately engage in the process, where does the child or the young person's focus or voice get heard? How does it get heard? 

MR TRACEY:  That depends on the individual case. So, it may be that an advocate is engaged by the clinical service. It may be that a member of the extended family is engaged. It depends on the individual circumstances of that family and that child. 

MS MAHONY:  And in terms of Kaleb and Jonathon's situation, did the Department of Health or hospitals take any steps to ensure that they had a voice independent of Paul Barrett? 

MR TRACEY:  My response to that would be, it would be unusual for our paediatric services not to have explored those alternatives and that would be done   the mechanism for doing that would be through child protection, our child protection team, our forensic team, and that the initial conversations around that would go to the SCAN process. 

MS MAHONY:  So, again, it relies upon the integrity of the SCAN process meeting a   I withdraw that. If we go back, it depends upon the position of the child or the young person being engaged with the hospital. 

MS PAYNE:  In cases where children are flagged of being at risk or there is a suspicion that they are at risk, that's the mechanism. In instances where children who have parents who at times may disagree with a particular approach, that's usually resolved through engagement with the parent or the parent's broader network or even their legal team, on occasion. It's solely case dependent. 

MS MAHONY:  When you talk about clinical care of Kaleb and Jonathon in your statement, you rely upon the footnote that I took you to before at footnote 6 and 7. I'm just going to take you to a couple of those documents now. The footnote that ends with the second one on footnote 6   I'm sorry, footnote 7, the first one on footnote 7 ending in 0033.0002, that is a document relating to Kaleb, and it documents each of the attendances at the hospital for the duration of his life up to 2020; is that correct? 

MR TRACEY:  That's correct. 

MS MAHONY:  Once Kaleb was not in the care of the   in foster care, does it surprise you that on 9 August 2002, there was a failure to attend an appointment with the audiology. There was a general paediatrics child advocacy service on 22 October 2002 where there was a failure to attend. There was another audiology failure to attend on 3 February 2003. And if one goes through this document, there are repeated non attendances. You're aware of that, aren't you? 

MR TRACEY:  Yes, I am. 

MS MAHONY:  2004, failed to attend general paediatrics on a number of occasions. 2005, failed to attend on four occasions. 

MR TRACEY:  That's correct. 

MS MAHONY:  How can   and you accept, don't you, that putting aside emergency attendances where Kaleb has been brought in for other purposes, there was very little and very irregular engagement by Kaleb through his father at the hospital; correct? 

MR TRACEY:  Correct. 

MS MAHONY:  So on that basis, you would have to agree, wouldn't you, that there could not have been clinical care being provided to Kaleb because he could not be seen, he wasn't being seen, he wasn't being examined, he wasn't being diagnosed, all those indicia that you spoke of, of clinical care. 

MR TRACEY:  I'm not sure I understand your question. 

MS MAHONY:  Well, I'll put it another way. If someone is simply not attending appointments, you're not providing clinical care, are you? 

MR TRACEY:  Well, that's   that's correct. However, within the context of providing clinical care, parents and children and young people often do not attend appointments for a whole variety of reasons. In this instance, if this young person wasn't, and didn't attend appointments, we do have in place processes that would follow up. Our social workers would have followed up, et cetera, and those issues, then, in relation to these young boys' care would have been flagged through the SCAN process. 

MS MAHONY:  But the point being that, in your statement, you say that:

    ‘A high quality provision of clinical care to both of them.’

MR TRACEY:  Yes, that's correct. 

MS MAHONY:  But they simply did not attend the hospital on a sufficient basis to be able to be provided with any continuity of clinical care; correct? 

MR TRACEY:  Continuity is quite a different matter, but in terms of their attendance at the hospital, I'm confident that the care that these children and young people received was of a high quality. 

MS MAHONY:  They had never received a medical diagnosis, had they, prior to Paul Barrett's death? 

MR TRACEY:  I can't comment on that. 

MS MAHONY:  If that was the case, that would indicate that one of those indicia of high quality clinical care had not been met; correct? 

MR TRACEY:  I can't comment on that. It's an inference that you draw. 

MS MAHONY:  In terms, then, of the independent review that was undertaken by the Queensland Family and Child Commissioner, you refer to that at page 18 of your statement, and at page 18 you talk of there being   two reviews then conducted:  A review conducted by the Child Death Review Board and a review conducted by the Family and Child Commission; correct? 

MR TRACEY:  Correct. 

MS MAHONY:  Where did you form the view that there were two reviews undertaken? 

MR TRACEY:  The   my understanding is that's where we worked through the paperwork that   that indicated that there were two reviews that were either undertaken or at least one of them was planned to be undertaken while the other one was  undertaken. 

MS MAHONY:  There's a difference between one being planned to be undertaken and one being undertaken; correct? 

MR TRACEY:  I accept that. 

MS MAHONY:  And are you aware that the Child Death Review Board did not and has not undertaken any investigations into the circumstances of Kaleb and Jonathon? 

MR TRACEY:  No, I was not aware of that. 

MS MAHONY:  In terms of the fact that no particular review has been conducted into the individual circumstances of Kaleb and Jonathon, is that not a matter that   I withdraw that. Does that not mean there are still systemic issues that may be floating about that impact on the provision of care by hospitals to those now adults that have gone missed?

MR TRACEY:  If I understand your   your assertion correctly, yes, I agree. I think there is room for improvement in how we are connected across the system and particularly for children and young people who are vulnerable, as is the case with these two young men. 

MS MAHONY:  And in that regard, given particularly the concession you've appropriately made about some of the deficiencies in the SCAN process, and knowing now as well that a review into the individual circumstances of Kaleb and Jonathon had not been conducted, do you consider that it would be of benefit to the   to Health, to [Hospital], to undertake or to your department, at least, to undertake a review now?

MR TRACEY:  I   I would consider being   that a review would be helpful because the outcome of any review should be to teach us lessons about how to improve the things that we do, and improve our approach. I don't believe in this instance that it is specifically a matter for Health to conduct an overall review, but I do believe that we can contribute to a systems review in the way that we're doing now. 

MS MAHONY:  And you'd certainly agree, based on all the evidence that you've read now, that Kaleb and Jonathon came to the attention of the hospital in circumstances where there was signs of neglect and abuse present? 

MR TRACEY:  At a very early age. The record would support that. In fact, at birth. 

MS MAHONY:  And I suggest to you that the absence of continual attendances or non attendances was indicative of ongoing neglect? 

MR TRACEY:  That may not necessarily be the case. I can see that, with the benefit of hindsight, in this case, that is true, but in other circumstances, often for one reason or another, families move frequently and   

MS MAHONY:  And that's certainly, though, one of the reasons why there would be utility in conducting a review to ensure there are no gaps. So, clients and patients and young people like Kaleb and Jonathon are not missed? 

MR TRACEY:  I would agree. 

MS MAHONY:  And do you also accept that had there been greater follow up and contact between your department, the Health services, and Kaleb and Jonathon, it may well, and probably would have prevented the continuation of the circumstances of neglect those young men were found in? 

MR TRACEY:  I can't say that for certain. 

MS MAHONY:  It's likely though, isn't it, having professionals engaging with young people through a medical lens, they would have been alert to circumstances that would have prevented the young people presenting to hospital with that severe malnutrition on 27 May 2020. 

MR TRACEY:  I think anything that we can do to prevent distress and jeopardy to children is an important thing for us to consider how we go about that. 

MS MAHONY:  Your Honour, that's   Chair, they're the questions that I have. I just note we're quite pressed for time in terms of questions.

COMMISSIONER McEWIN:  Thank you, Ms Mahony. I'll ask my colleagues if they have any questions, and if they do we'll try and keep them brief. Commissioner Mason? 


COMMISSIONER McEWIN:  Commissioner Ryan. 

COMMISSIONER RYAN:  No, thank you.

COMMISSIONER McEWIN:  No questions from me. Thank you very much, Mr Tracey, for your contributions. We're very grateful. You may now be excused. 


COMMISSIONER McEWIN:  Ms Eastman, what next? 

MS EASTMAN:  There's one witness, Chantal Raine from the Department of Communities, Housing and Digital Economy, and that will be the final witness. I understand she's taking an affirmation.


COMMISSIONER McEWIN:  Thank you Ms Raine. We're very grateful that you've come to provide us with your evidence and for the materials that you've given us. I'm Commissioner McEwin. This is Commissioner Mason, Commissioner Ryan. The associate, who you can see just to your right, will read out the affirmation. Thank you. 

THE ASSOCIATE:  I will read you the affirmation. At the end please, say yes or I do. Do you solemnly and sincerely declare and affirm that the evidence which you shall give will be the truth, the whole truth and nothing but the truth? 

MS RAINE:  I do.


COMMISSIONER McEWIN:  Thank you. Ms Eastman.


MS EASTMAN:  Thank you. Ms Raine, thank you for joining us.  Can I confirm that you are Chantal Raine? 

MS RAINE:  I am. 

MS EASTMAN:  Might just keep your voice up. 

MS RAINE:  I am. 

MS EASTMAN:  Thank you. And you are the General Manager, Service Delivery within the Housing and Homelessness Services within the Department of Communities, Housing and Digital Economy? 

MS RAINE:  Yes, I am. 

MS EASTMAN:  You prepared a statement in relation to this case study on 5 May. 

MS RAINE:  Yes, I did. 

MS EASTMAN:  Have you had a chance to read the statement? 

MS RAINE:  Yes. 

MS EASTMAN:  Are its contents true and correct? 

MS RAINE:  Yes. 

MS EASTMAN:  Now, in the time that I have available, which is less than six minutes, I just really want to get to two substantive points. The first is are the Royal Commissioners right in understanding that the perspective from your department is you have no mandatory reporting obligations? 

MS RAINE:  That is correct. There are no mandatory reporting obligations. 

MS EASTMAN:  So when it comes to staff who work within the department who may be required to attend premises to effect repairs, to do cleaning work or broader maintenance work, if those staff see circumstances that might indicate a child who has experienced violence, abuse or neglect, or are at risk of any significant harm, the department's position is there's no obligation on the staff member to report those circumstances; is that right? 

MS RAINE:  The department's position is that those types of matters do need to be escalated and discussed with senior managers within   within the staff member's workplace. 

MS EASTMAN:  Within the department, not outside the department? 

MS RAINE:  Within the department, who then work with the staff member, and then they look at further escalation in combination with that staff member, which may mean that they refer to other agencies and   and also undertake reporting to services such as the Queensland Police Service and Child Safety. 

MS EASTMAN:  And who ultimately decides that? The most senior person at the end of the reporting line? 

MS RAINE:  It's actually within the workplace, within the operational team. So, we encourage our staff to work in combination with other managers within their team. The staff member can, in their own right, make contact, but we do encourage in a supportive fashion for them to work with senior managers within their team. 

MS EASTMAN:  And you accept that the staff of the Department of Housing may have some unique opportunities to actually go inside the homes of people. You agree with that? 

MS RAINE:  Yes, I do agree with that. 

MS EASTMAN:  And while you've said in your statement that one doesn't make a judgment of the state of somebody's home on one visit, would you agree with me that there may be some indications on some occasions that the state of a person's home might give rise to a risk of neglect, particularly if there are children in the home? 

MS RAINE:  Yes, I do. 

MS EASTMAN:  So if, for example, there were no handles on the door, there were gates, that there was a smell of faeces, that there were piles of clothes with maggots, maggots in food and piles of clothes with bugs, there were stains, there was a smell, those would be the sort of indicators that your staff would say this might be a problem? 

MS RAINE:  Yes, that's correct. And those are the indicators and some of the indicators that we do expect staff to then seek further assistance and support through their workplace, and also through to other agencies. So, yes, they have undertaken training and have been provided with a range of programs that help them to now gauge or to pick up on signals within the home. And they do have access to a specialist response team within our broader service delivery team that they can also seek   and this is a team of specialist staff that specialise in   specialise in areas such as domestic, family and sexual violence, as well as people with disabilities, et cetera. So, they have the ability to reach in. And the expectation today in practice is that they would be working and would be seeking other supports, if they do walk into a house and are seeing those types of things that you've described. 

MS EASTMAN:  And you're aware from reading the proposed agreed facts that there were many occasions where staff from the Department of Housing had the opportunity to see both the outside of the boys' homes and also inside; is that right? 

MS RAINE:  Yes, I am aware. 

MS EASTMAN:  And it wouldn't have mattered whether or not the boys were there or not for those staff to make an assessment about the living arrangements. You'd agree with that? 

MS RAINE:  Yes, that's correct. 

MS MAHONY:  And after Paul Barrett's death, there was an officer within the department who undertook a review of the department's documents to identify if there may have been opportunities that the Department of Housing staff might have brought to the attention of Child Safety or other relevant agencies; is that right? 

MS RAINE:  That's correct, the area manager at the time. 

MS EASTMAN:  And in terms of that review, is it your position that it's not a reliable review or is your position that that review constituted a proper and appropriate response in the circumstances of Paul Barrett's death and the condition in which the two young men were found? What's your position? 

MS RAINE:  In my view, that was a informal review that was undertaken by the area manager of the Housing Service Centre at the time. And it was a review which was looking over a short period of time and was primarily focused on trying to draw out the relevant information which was then to allow us to be able to act in a way that had as much information as possible available to us to respond and look at alternative housing assistance for Kaleb and Jonathon. 

MS EASTMAN:  So you're saying the purpose of that review was to look for alternative housing for the two young men rather than returning to a house that you knew would require a significant deep clean to make it habitable for them; is that right? 

MS RAINE:  No. What I am saying is that the purpose of the review was to look at what information we did have available to us in regards to the property, the tenancy, and it did form some of the information that then we considered when we moved into the stage of looking and working with a range of agencies, including the NDIA, in relation to suitable accommodation options. 

MS EASTMAN:  But you're not saying to the Royal Commission that you're critical of your own department's review, are you? 

MS RAINE:  What I am saying to the Royal Commission is that I have looked across the extensive records of the tenancy of Mr Barrett, and that's from 2004 to 2020. That has   and I am acknowledging that there are occasions where our staff did come in contact with information through Mr Barrett at the time, that, in current times and practice, the expectation would be that they would have sought out further assistance and looked to potentially other   other agencies and other forms of assistance. And so that is what I am acknowledging, that there were occasions across that time period where   where the actions could have been that they sought further advice and that they came across information via Mr Barrett, in terms of what he communicated to   to our staff, that could have meant that they could have sought additional assistance. 

MS EASTMAN:  So, that's the type of information that could have been brought to the attention of Child Safety or the police; you accept that? 

MS RAINE:  Yes, there are   there are some occasions where there is information that could have been brought to the attention   

MS EASTMAN:  That's a yes. 

MS RAINE:    of Child Safety, yes. 

MS EASTMAN:  And you accept that given the unique circumstances of Department of Housing staff being able to go into the property that the Department of Housing staff can play a role in ensuring the safety and the protection of children. You accept that? 

MS RAINE:  I do, and, in current practice, that is very much the case and it is very much what we have done over the recent number of years in terms of investing in building our staff's capability  

MS EASTMAN:  Sorry to jump in. I know we're short on time but I just wanted you to answer my question of whether you agreed that there was a role for the department

MS RAINE:  There   yes. 

MS EASTMAN:  Is that right? 

MS RAINE:  Yes. 

MS EASTMAN:  Thank you, Commissioners. Those are my questions.

COMMISSIONER McEWIN:  Thank you, Ms Raine, for your contributions. I will just quickly check with my colleagues if they have any questions for you. 

COMMISSIONER RYAN:  I'd love to but I think we've covered it, so I won't press it.

MS RAINE:  Okay.

COMMISSIONER McEWIN:  Thank you. Commissioner Mason? 


COMMISSIONER McEWIN:  Thank you again, Ms Raine. We're very grateful for your appearance. I know time constraints. We would have liked to have had more time; however, we're under some time constraints. I'll just check with the parties with leave to appear if there are any questions. Ms McMillan? No. Okay. You may be excused. 

MS RAINE:  Thank you. 



MS EASTMAN:  Yes. So, two things. We don't require Dr Crawford, and if she has remained we're grateful that she has remained, but she doesn't require to return to the witness box. That's the first thing. 

The second is we started this hearing by saying this must remain person centred and that while we talk a lot about Kaleb and Jonathon, we have to remember that this hearing is about them, and so we've been asked to share with you, Commissioners, and those following the hearing a little message from one of the young men who would like us to show this photo. That's one photo, and I think then there's one more. So, they'd like us to tell you that they're continuing on their journey and that this photo represents the continuation of their journey and looking forward to the future. 

Commissioners, that concludes the evidence for this case study. What remains outstanding, Commissioners, are the proposed directions. Commissioner McEwin, I know you have a copy of the directions. It's agreed with the exception of one matter. I understand that our learned friends from Queensland would like additional time with respect to proposed order 1. 

In our respectful submission, if there is an extension of time in relation to proposed order 1, that will have implications for the whole of the timetable. We are acutely aware that the Royal Commission is coming to an end, and that the timeframes in which we have available to complete submissions, consider submissions in reply and for the Commissioners to prepare a hearing report following this hearing are so tight that the extension of five days would create a jeopardy to the whole of the timetable. 

So I appreciate our learned friend's concern, but in my respectful submission, the dates should remain as they are. Commissioner McEwin, you may wish to hear from Ms McMillan, but otherwise, I understand the balance of the directions are agreed. 

MS McMILLAN:  Yes, well, obviously, in order we have, then, two workings days left to be able to ascertain any information on notice. It is a very short time. If it's not Friday, then at least perhaps Wednesday next week so that we can just have a few more days to marshal information.

COMMISSIONER McEWIN:  Ms Eastman, you want to reply to that? 

MS EASTMAN:  Can I make a suggestion that we keep the directions as they are, and that if on Monday our learned friends have difficulty meeting that or if there's some outstanding matters, that they can bring that to the attention of the Office of Solicitor Assisting and arrangements can be made as to what any relevant extension might be.

COMMISSIONER McEWIN:  Ms McMillan, do you have a response to that? I should clarify, I think it's three working days that you have. I assume it will be 5 pm on Monday.  So it's tomorrow, Friday and then Monday, so three working days, I think, given our circumstances, and I can stress to you the very tight deadline. However, do you want to respond to that last comment? 


COMMISSIONER McEWIN:  Thank you, Ms McMillan. Anything else from the other parties before I read them out? 

MR ANDERSON:  No. Thank you, Chair.

COMMISSIONER McEWIN:  Thank you. I will now read out the directions for this Public hearing 33. 

1. Any witness who took questions on notice during the hearing should provide their answers in writing to the Office of the Solicitor Assisting the Royal Commission by Monday, 15 May 2023. The answers should be targeted and concise and not address additional or unnecessary matters. 

2. By Monday, 22 May 2023, Counsel Assisting the Royal Commission will provide a list of any additional documents she wishes to tender into evidence, including responding to the questions on notice on a confidential basis to the parties with leave to appear at this hearing. 

3. Parties with leave to appear should advise the Office of the Solicitor Assisting by Friday, 26 May 2023 if they wish to suggest any additional documents for tendering by Counsel Assisting. At the same time, they should identify any parts of those documents that they consider need to be redacted before the documents are made public. 

4. Counsel Assisting will tender those documents into evidence which she considers appropriate in chambers by Tuesday, 30 May 2023. 

5. Counsel Assisting the Royal Commission will prepare written submissions following the hearing by Friday, 2 June 2023. These submissions will be provided on a confidential basis to parties with leave to appear for this hearing and any other individuals, entities or organisations Counsel Assisting the Royal Commission considers to have a substantial interest in this hearing. 

6. And final, any responses to the Counsel Assisting's submissions should be sent to the Office of the Solicitor Assisting by Friday, 23 June 2023. Those responses should be concise and should not include any additional evidence. 

So that concludes the directions. Ms Eastman, are there any other matters before I make some closing remarks? 

MS EASTMAN:  No. Thank you, Commissioners.

COMMISSIONER McEWIN:  Thank you, Counsel. On behalf of the Commissioners, I express our appreciation to all those who have been responsible for preparing and conducting the hearing. The preparation for these hearings requires a great deal of time, resources and skill. Every person who has engaged with the Royal Commission has brought invaluable information to the hearing. 

We would like to thank them all personally for their contribution. We were unable to hear from Kaleb and Jonathon, the young men who are the focus of the hearing. We do appreciate the closing remarks from Ms Eastman and the message that they passed on. We were particularly assisted by Lisa Hair, a friend of the young men. We thank her for coming to the Royal Commission and providing us with the insight into Kaleb and Jonathon's life prior to their father's death. 

Her evidence was incredibly important for keeping Kaleb and Jonathon at the centre of the issues discussed during the course of this hearing in circumstances where we were unable to hear from them themselves. 

Alexis, from Service Provider A, told us about the services and supports now received by Kaleb and Jonathon, their activities and their plans for the future. Scott McDougall, Queensland Human Rights Commissioner, told the Royal Commission about the operation of the recently introduced Human Rights Act in Queensland from January 2020. The Act imposes obligations on public authorities to make decisions and act consistently with human rights. 

Thank you to all the representatives from the various Queensland departments and the NDIA who came to give evidence this week. We are always grateful for their cooperation with the Royal Commission and for the information provided in written and oral form during the course of the week. Thank you also to their legal representatives from Queensland and the Commonwealth. We acknowledge the work that has been involved from their end in preparing and responding to the hearing. We thank them for their cooperation. 

Preparing for and conducting the Public hearing has required an enormous effort from many people. Ms Kate Eastman AM SC and Gillian Mahony, Counsel Assisting the Royal Commission have done a superb job gathering and presenting evidence for this hearing. Counsel has been very ably assisted by Kate Dobbie's team from the Office of the Solicitor Assisting, who have done an enormous amount of essential background work in compiling and analysing information from a variety of sources, liaising with witnesses and assisting in presenting the information. 

We thank the counselling team for providing dedicated support to witnesses who have appeared in this hearing. We also thank and appreciate the work of the corporate team, including logistics and information technology. We also thank the interpreters and the critical role they play in the accessibility of the hearing. Thanks also to Law in Order for the technical support they have provided. It is a great credit to them that the hearing has proceeded as smoothly as it has and as so many other hearings held by the Royal Commission. 

While this hearing has been presented as a case study and witnesses have given evidence specific to the case study, the evidence we have heard is important more broadly. The case study highlighted the importance of taking a life course approach to examining the experiences of people with disability from infancy, childhood, adolescence and a young adult, and their intersecting experiences with various departments. 

Life course approaches consider the timing of influences, events and experiences over a person's life. It highlights that experiences during clear transition periods can have particularly significant impacts on life outcomes. For people with disability, this life course approach highlights that their life experiences can be enhanced or restricted by the institutions and organisations they interact with. So, thank you again to everybody. 

While today marks the conclusion of our substantive hearing program, the Royal Commission will remain very busy between now and when it delivers its final report to the Governor General in just under five months’ time. Over the next few months, the Royal Commission will continue with its What Australia Told Us information session which aim to inform people with disabilities, their families, carers, advocates and other stakeholders about the Royal Commission's work over the past four years. 

Most of those events have been held in Brisbane, Sydney, Canberra and Perth so far. The remaining sessions will be held in Darwin on 16 May, Alice Springs on 18 May, Melbourne on 13 June, Adelaide on 15 June and virtually on 19 and 22 June. Members of the public can register to attend these sessions by following the link on our website. The sessions provide information to the community on what we have done over the course of our inquiry, including how people have engaged with us, who we heard from, ways people shared their experiences and what we learnt from people who participated in engagement, private sessions and submissions. 

In addition, over the next few months, the Royal Commission will hold its last lot of private sessions, with those who registered prior to registration closing at the end of 2022. Once concluded, nearly 1800 members of the Australian public will have engaged with us through the private sessions process. 

In terms of other work, the Royal Commission has a number of research reports which it will publish between now and August 2023 and we will look to publish a report of this hearing, Public hearing 33, by early September 2023. 

More importantly, there is extensive drafting work going on right across the Royal Commission as we look to promote through our final report a more inclusive society. A society that supports the independence of people with disability and their right to live free from violence, abuse, neglect and exploitation. 

Finally, while this is the Royal Commission's last substantive hearing, we will hold a ceremonial closing hearing in Sydney on 15 September 2023 in advance of delivery of our final report at the end of September. This closing ceremony will be open to the public, who are encouraged to attend. Information, including location of the ceremonial closing hearing, is available on our website. 

Thank you again to everybody. This concludes the hearing this week, and we will adjourn at 10 am on Friday, 15 September 2023 in Sydney for the ceremonial closing hearing.