A Territory Families-approved carer accused of making a foster child drink sour milk "as a form of punishment" was allowed to continue in the role despite 10 investigations into her suitability, a report by the Children's Commissioner has revealed.

Key points: Woman approved as carer, despite child protection notifications relating to her own children

Woman approved as carer, despite child protection notifications relating to her own children Five complaints of neglect, emotional harm or child safety substantiated by child services between 2015-16

Five complaints of neglect, emotional harm or child safety substantiated by child services between 2015-16 Decision to authorise carer "not verifiably sound", report finds

The report tabled in the Northern Territory Parliament on Wednesday night, in conjunction with an independent review into the alleged rape of a two-year-old girl in Tennant Creek, outlined an investigation into the carer's conduct.

It detailed what Children's Commissioner Colleen Gwynne described as a failure of duty of care by child protection services.

The woman, dubbed 'FC', was subject to 10 child protection investigations relating to physical abuse, neglect or emotional harm between 2015 and 2016, five of which were substantiated.

Of the substantiated notifications, four related to the "neglect and emotional harm" of two siblings placed in FC's care during 2016, who were ultimately removed.

"Child safety concerns" were supported in the case of a third child, residing in the woman's home between 2015 and 2017.

During an interview with two of the children in 2016, Territory Family workers found them to be of poor hygiene and said they "smelt strongly of urine".

The report stated:

"They described the carer as cruel and that they were taken out of their beds at night and told the demons will come and get them. They said that she takes the kids 'far out bush' and C4 was made to stand alone in front of the car headlights to wait for the demons… The carer also made C4 drink milk that had gone 'off', as a form of punishment for eating and drinking without her permission."

The report outlined additional concerns raised with Territory Families by the biological mother of two of the foster children, including that they had not been fed, "were begging their carer for food" and presented with urine-soaked clothes.

In one incident, the woman told child protection workers she did not help an eight-year-old foster child who had cerebral palsy and a cast on her leg change after she wet herself because: "I am not playing that game."

Home 'posed a health and safety risk' to children

The report found Territory Families failed in its duty of care to provide a total of five foster children the "required care and protection to safeguard them from harm", primarily due to being placed with a carer who "had not been subject to a proper assessment process".

It identified a number of issues around subsequent child protection investigations involving FC, including:

Inconsistent decision making by case managers during investigations

Inconsistent decision making by case managers during investigations Delays in responding to reported child protection concerns

Delays in responding to reported child protection concerns Incomplete evidence being relied upon regarding subsequent notifications and previous investigations

Incomplete evidence being relied upon regarding subsequent notifications and previous investigations Deficient record keeping

Deficient record keeping Failure to complete documentation

In one case, during a home visit in 2016, no issues were identified by a case manager responding to concerns around the living conditions of three children.

However, just nine days later another case manager conducting a second home visit determined the premises was "grotty and unhygienic" and "posed a health and safety risk to the children".

The children were forced to sleep in sectioned-off areas in the lounge room separated by curtains, the report found, and both rooms "smelt strongly of urine".

The team leader ultimately directed a Placement Respite Form be actioned to identify a new home for two of the foster children.

The third child, a toddler, remained in the care of FC.

"It is of significant concern to the OCC [Office of the Children's Commissioner] that in the view of one CM [case manager] there were no issues identified during the home visit … and yet nine days later … another CM and her team leader were so concerned … they immediately sought an alternative placement for [the children]," the report read.

"Investigations were not conducted in accordance with policy and procedure, and were sometimes incomplete. Subsequently, the risks regarding this carer were not accurately captured.

"This, combined with the lack of proper case management, left the children extremely vulnerable and resulted in further neglect and harm."

Territory Families did not revoke carer authorisation

The report found child protection notifications relating to the woman's biological children dated back from as early as 2003, and other children in her care from 2012.

The reports related to concerns around hygiene, neglect, harm and her state of mind.

"If a review of historical child protection records and information related to FC was conducted … the decisions regarding her suitability as a carer would have been brought into question," the report noted.

"[Territory Families] continued to place children with this carer, while there were ongoing 'child concern in care' investigations."

Territory Families CEO Ken Davies said many of the recommendations aligned with ongoing work ( ABC News: Mitchell Woolnough )

It also determined there were "inconsistencies" in the response to the 'child concern in care' investigations, including the removal of some children as a result of concerns for their welfare, whilst leaving a young and vulnerable toddler in the placement.

However, despite the occurrence of 10 separate investigations, the Office of the Children's Commissioner noted that Territory Families did not revoke the woman's authorisation to foster children.

Rather, her authorisation was cancelled following her decision to cancel her registration as a carer, while attempting to gain reauthorisation.

The report concluded that Territory Families' decision to authorise and reauthorise the woman as a carer "was not verifiably sound", and made 14 recommendations, including community services checks of prospective carers and quality assurance checks of children in care.

In a response to the report, Territory Families CEO Ken Davies said many of the recommendations were "well aligned" to work in progress.