Liana Buchanan says there was always one moment, when reading the stories, she was stopped in her tracks and had to go to "for a cup of tea or a walk".

And she is used to tough material.

It is her job to protect children, as Victoria's Principal Commissioner for Children and Young People.

But delving into the stories of 35 Victorian children who died from suicide despite coming into contact with the child protection system in the year before their deaths made her "profoundly sad".

"It [also] makes me profoundly angry, if I'm honest," she said.

Ms Buchanan's team examined the traumatic lives and the systemic failures throughout them in Lost, Not Forgotten, a report tabled today in State Parliament.

She said they included stories of children found throwing up after they had watched their mothers being seriously assaulted, or hiding in the back garden due to the level of fear they experienced.

"I think of some of the children who [were] reported as going to school routinely with rotten, rancid food, with lice and bites covering their body, with scabies, a whole raft of other health conditions connected with neglect," Ms Buchanan said.

"They might know that child protection's come to visit their family, but they know that nothing's getting better.

"As a consequence, the extent of powerlessness that I imagined those children feel is pretty devastating to imagine."

Where the system is letting kids down

Ms Buchanan commissioned the report to identify the failures in each case and found a common, troubling theme.

Each child fell into the current gaping hole between coercive interventions and voluntarily-attended family services.

They became subject to a "roundabout" of protection reports leading nowhere.

At the most, child protection services would refer the case to a child and family service before closing their case.

The problem was, when the child and family service tried and failed to contact and engage with the family, they closed the case on their side too.

"The net result of all of this is that these children living with significant violence and neglect, continue to live with that with no intervention," Ms Buchanan said.

"It simply beggars belief that a family that's demonstrated a lack of engagement with child protection is sent a letter suggesting they contact other services."

Half of the children were reported to have been sexually abused.

They each had repeated contact with child protection services — an average of seven reports per child.

One child had been the subject of 25 reports.

Several saw their mothers experience physical and sexual violence.

One child was described as "hungry, filthy and had flea bites all over his body".

Yet in 90 per cent of the 35 cases, child protection workers decided in the initial stages of investigation there "wasn't enough risk" to the child for them to intervene.

They usually never talked to the child by themselves, away from family members who might be abusing them — another disturbing common factor that the commissioner wants to address.

'He was put in the too hard basket'

Natasha Anderson feels that perhaps if there had been early intervention for her family, she would not have lost her brother Matt to suicide in 2014.

As a family violence survivor she knows how important early, persistent and consistent intervention is.

"My brother loved my mother more than anyone in the world," she said.

"And so for him, when he came to coming into care, he would always run away, back to my mother because that's where he wanted to be.

"He was really traumatised. He had difficulty engaging with schooling, he was basically someone who had just disengaged from everything and falling through the cracks because he was put in the too-hard basket."

Family violence survivor Natasha Anderson now works to improve Victoria's child support services. ( ABC News: Michael Barnett )

Ms Anderson made an animated film about her experiences and now talks to policymakers.

She said a focus on talking to the child was long overdue and remembers strangers visiting her home, but not talking to her.

"If you're only speaking to the parent, you're only getting a very specific side of the story … that young person might be being abused by that parent," she said.

"And there's no way to know unless you talk to them. And it shouldn't be in the same room as the parent.

"When a child or young person says this has happened to me, it's about believing them and about helping them get to a point where they can recover."

Ms Anderson also said children who displayed destructive behaviour were often labelled as "bad" and not granted the same opportunities as other children.

"They'll end up perpetuating the cycle of violence and intergenerational trauma," she said.

What needs to change?

Ms Buchanan said the repeated failures to pursue a child's welfare were hallmarks of an under-resourced and overstretched system.

The report made six recommendations, including more funding to engage hard-to-reach families earlier, making specific guidance for workers to make sure they asked children what was happening to them away from family members and tracking families' engagement.

Ms Buchanan said that could mean using existing laws to coerce more families to engage with child welfare services.

"I think there's absolute potential for that," she said.

"There may well be a place not to remove children, but to use the statutory process more to make sure that the families are engaged.

"By nature, these families, the adults in them, have a whole lot of issues going on. They're not necessarily ready or able to respond to a letter to go and see a service, or to respond to a call and then just begin to engage regularly.

"We need a much more intensive and sophisticated system to be honest."

The commissioner said while there had been investment in child protection in the past few years, the same was not true for the early intervention child and family services, despite the need being recognised in the State Government's Roadmap for Reform policy launched in 2016.

Ms Buchanan said the Government needed to come good on that promise, to help children avoid the same fate as the 35 children whose lives she studied.

"There's many young people I meet who've been through similar experiences, and who have survived them. So I hang on to that, to be honest," she said.

"I hang on to the knowledge that many young people are incredibly strong, incredibly resilient.

"But ultimately, we've got to make the system better so that this doesn't happen for the children who ultimately died here, but also that all children who have difficult experiences at home, get the protection they need."

The State Government has accepted all the report's recommendations, and Minister for Child Protection Luke Donnellan said he would seek more money from this year's budget to boost services.

"Some of the issues over a period of time have been dealt with, which have been identified by the earlier cases, like earlier therapeutic intervention. But we recognise that our mental health [services] are in a difficult position here in Victoria and that's why we're having the royal commission," he said.

Ms Buchanan said she hoped "to see urgent investment and implementation"

"My concern is that these issues are affecting hundreds, if not thousands, of Victorian children right now," she said.