All of these children, aged between 12 and 17, had been in contact with a child protection worker - at an average of seven times - before they killed themselves. But in 90 per cent of cases, there was no follow-up. Shocking details of family violence, drug abuse, sexual abuse and extreme neglect are outlined in the report, which states that "most of the children came from families where trauma was entrenched and compounded by the 'toxic trifecta' of family violence, parental mental illness and substance abuse issues". Victorian Children's Commissioner, Liana Buchanan. Credit:Justin McManus One teen wrote to their child protection worker begging to be rescued from a mother who had stabbed herself with a kitchen knife: "Sorry about all this I feel really bad about it but it’s been years and I can't wait any longer. [Mum] can get really bad and she’ll scream and bash herself against the walls and I love her and she can be nice and she buys me lots of things and she really does care about me and love me but after all I’ve been through, I really need support and not only am I not getting support here, I’m having the negative temptations and stuff as well here. I’m really not safe here and it’s really scary and I’m sick of trying to be strong for the both of us all the time and being such a failure at it all." The 15-year-old died by suicide two weeks after Child Protection closed the case.

Child protection lodged a total of 229 reports related to the children, of which 78 were closed immediately and others were lost in a resource-stretched and poorly organised system of referrals. "Despite repeated interactions with the child protection system, the risk to these children and young people was left to escalate as they fell into the gaps between services," Ms Buchanan said. Almost all the children - 94 per cent - endured violent fathers, including children who had seen their mothers raped, beaten and strangled. Half of the children had been sexually abused. One child abused by a number of men, including the stepfather, was only seen once by a child proptection worker, despite six separate reports to authorities of sexual abuse. The complaints were never followed up. Most had been neglected: 89 per cent of the children experienced neglect, with reports of flea bites, blackened teeth, scabies and children wandering the streets or sleeping in filthy homes with no food.

Six of the 35 children who took their lives were Aboriginal, a finding Commissioner for Aboriginal Children and Young People Justin Mohamed said was "sadly unsurprising" because Aboriginal children were already over-represented in out-of-home care. None of the children was ever assessed away from their parents, Mr Buchanan said, even though this is contrary to guidelines for interviewing children at risk. "These are children who will often still deeply love their parents but they are also known to be very afraid of their parents and or feel it would be disloyal to their parents to speak up. There are obvious reasons to speak with children away from parents when assessing risks." Minister for Child Protection Luke Donnellan said "every suicide is a tragedy". "And with the latest data sadly showing more than 500 Victorians died by suicide in 2018, we know there's more to be done in its prevention, particularly for our young people," he said in a statement.