Key Takeaways
- Over a 15‑year span, Queensland Health staff repeatedly missed chances to report child‑safety concerns for two disabled brothers, Kaleb and Jonathan.
- The boys were discovered in May 2020 locked in a naked, severely malnourished state; their father, their primary carer, was found dead in the same home.
- Despite numerous missed specialist appointments and earlier reports to child protection (2000‑2005), Queensland Health failed to make further referrals to Child Safety.
- The Queensland Ombudsman’s independent review blamed the health department for inadequate guidance, inconsistent child‑protection training, and fragmented information‑storage practices.
- The Disability Royal Commission recommended a formal government apology (delivered September 2023) and compensation for the brothers; the ombudsman’s report adds 13 concrete recommendations to prevent similar failures.
Background of the Case
The ombudsman’s 48‑page report examined the interactions between Queensland Health and two siblings, pseudonymously named Kaleb and Jonathan, who were diagnosed with significant global developmental delay and intellectual disability. Emergency services found the boys in May 2020 living in squalor, locked in a room, naked and severely malnourished, while their father—who acted as their carer—was discovered deceased in the Brisbane residence. The case was later scrutinised by the Disability Royal Commission to assess whether the boys suffered violence, abuse, neglect, or deprivation of human rights during childhood and adolescence.
Pattern of Missed Health Appointments
Between 2005 and 2020, Kaleb and Jonathan missed numerous appointments with Queensland Health specialist services. Although clinicians recorded the non‑attendance, follow‑up actions were inconsistent or absent. Earlier concerns raised with child protection between 2000 and 2005 did not trigger additional referrals from Queensland Health, leaving a gap in protective oversight that persisted for over a decade.
Education Sector Observations
The ombudsman’s first report, released in April 2025, highlighted that special‑school staff had almost daily contact with the brothers during their school years. Educators noted inadequate clothing, insufficient food, frequent urine and dog‑odour smells, and occasional passage of rocks and pebbles in bowel motions. Despite documenting these issues in the department’s information system, only a single student‑protection report was forwarded to Child Safety, illustrating a missed opportunity for early intervention.
Ombudsman’s Findings on Queensland Health
Anthony Reilly’s third report concluded that Queensland Health fell short in several key areas. Staff received limited guidance on recognising that missed outpatient appointments could signal neglect. Child‑protection training was not delivered consistently or regularly across hospital and health services, with one service reporting no training at all.
Information‑Management Deficiencies
The investigation found that child‑protection information was stored inconsistently—some services used paper records, others electronic systems, and many used a mix of both. When records remained paper‑based, they were confined to a single hospital or health service, hindering staff from viewing a complete picture of a child’s risk or identifying cumulative harm patterns. This fragmentation directly impeded timely assessment and response.
Queensland Health’s Response
In his written reply, Director‑General David Rosengren acknowledged the challenges posed by a geographically dispersed and decentralised health system. He affirmed ongoing efforts to advance the Digital Hospital Program, aiming to transition all services to a world‑class, digitally integrated platform. Rosengren also noted that, in recent years, nearly one in ten children fails to attend outpatient appointments—a rate higher than that of the general population—which the ombudsman deemed concerning.
Post‑Discovery Care and Current Status
After being found in May 2020, Kaleb and Jonathan received two weeks of hospital treatment for severe malnutrition before being placed into state care, with supports funded through the National Disability Insurance Scheme (NDIS). Both brothers are now in their twenties. The ombudsman’s office visited them while preparing the latest report, which includes 13 recommendations designed to strengthen safeguards.
Key Recommendations from the Ombudsman
The report urges Queensland Health to implement regular audits of a sample of missed outpatient appointments for children, to better detect neglect signals. It calls for the adoption of contemporary information‑management systems that allow seamless sharing of child‑protection data across services. Additionally, staff should be encouraged to consult their child‑protection unit whenever a concern arises, promoting this as best practice. Other suggestions include standardising child‑protection training, clarifying referral pathways, and improving inter‑agency communication.
Implications and Next Steps
The findings underscore systemic shortcomings that allowed prolonged neglect of vulnerable children with disabilities. By acting on the ombudsman’s recommendations—particularly the digital integration of records and uniform training—Queensland Health can close the gaps that left Kaleb and Jonathan unprotected for years. The Disability Royal Commission’s call for a governmental apology, already realised in September 2023, must now be complemented by tangible reforms to prevent recurrence and ensure that future cases of neglect are identified and addressed promptly.