"Incredibly brave and wise beyond their years."

That is how Victoria's Children's Commissioner describes the 35 children that she and her team came across as they worked through case notes to produce a damning report into children who took their own lives in Victoria.

The 'Lost, Not Forgotten' report spells out how Child Protection repeatedly closed cases despite knowing of severe abuse, neglect and self-destructive behaviours exhibited by the children.

They also failed to follow up on whether the families had sought help.

These are the words and stories of the children from their statements to Child Protection workers. Identifying details have been changed to protect them.

"I don't know whether I'll get nice mummy or horrible mummy." — A child whose mother struggled with substance issues and poor mental health, and whose partner regularly beat her to the point of hospitalisation.

Jane

Jane first came into contact with Child Protection when she was 12, and saw her first mental health service worker at the same time.

For a while, she had been a witness to episodes brought on by her mother's mental illness, including suicide attempts.

Jane witnessed many awful things. ( ABC News: Emma Machan )

Child Protection closed the report, with a referral to Child FIRST, a service used when workers believe the problems have a low to moderate impact on the kids involved.

It relies on families voluntarily turning up.

No-one referred Jane to have her own mental health assessed, because they believed Mum having treatment was enough.

Jane started to refuse to come home, and Child Protection was brought in again. This time they arranged for her to stay with another family member, and they made a second referral to Child FIRST.

But things went from bad to worse for Jane. Over the course of the next six months, she attempted suicide six times, taken to emergency departments each time.

Would being taken to hospital help Jane? She was referred to an inpatient facility, but following discharge she refused to engage with mental health services.

Any worker she met then wrote that Jane's mother's mental health and their difficult relationship was preventing Jane's effective engagement with services.

But nothing more was done to initiate engagement with the family.

Six more times, Child Protection was called for Jane, and every time Child Protection closed the case early on and referred the family to the voluntary Child FIRST service.

Mum and Jane never did turn up there.

"I'm really not safe here and it's really scary … [Mum] can get really bad and scream and bash her head against the walls and I love her and she can be nice and she buys me things and really does care about me and love me but like what I've been through [with her] I really need support … I don't know if that's good information or not but I thought it might help you guys understand that it's not like one huge thing that stops me from being okay here it's a lot of little things as well." — A child who witnessed her mother stab herself wrote this to her Child Protection worker. Child Protection closed the case. The child died by suicide two weeks later.

Jack

Jack was first reported to Child Protection at just three years old. Already, he had seen recurring family violence between parents caught up in substance abuse.

Then Jack's folks separated and started new relationships. But that wasn't a fresh start for young Jack, who saw his father seriously assault his new partner, strangling her to unconsciousness.

Jack became aggressive after witnessing violence at home. ( ABC News: Emma Machan )

When Child Protection looked at Jack's case, their concern was whether his mother was able to "act protectively" towards Jack.

No-one ever professionally assessed what impact this was having on Jack.

Jack was reported to Child Protection seven times throughout primary school — each report was closed almost immediately.

Twice, the family was referred to the voluntarily-attended Child FIRST services but they never turned up.

By 13, Jack's school was referring him to a mental health service for counselling. He attended every session but that wasn't enough — Jack started misusing substances himself and deliberately self-harmed. Eventually, he attempted suicide.

That promoted a referral to child and adolescent mental health services. They diagnosed Jack's depression in the context of childhood trauma.

But Jack continued to spiral, getting more aggressive, and he was placed in out-of-home care.

Jack was moved from home to home. ( ABC News: Emma Machan )

One of his parents told Child Protection the real problem was Jack's substance abuse and said rehabilitation was the answer.

But Child Protection never confirmed this with the counsellors who had actually linked Jack's state to his traumatic experiences. In fact, they never checked about his diagnosis or treatment plan, beyond his medication needs.

So everywhere Jack was placed, his would-be carers never got the full picture of what was going on with him.

Jack started missing appointments with his counsellors as he was bounced around from home to home and his substance abuse went increasingly unchecked.

His instability led his counsellors to note "there was very little work we could do at that time".