A recent report from the Queensland Ombudsman has been made public, detailing the interactions between healthcare professionals and two siblings, referred to as Kaleb and Jonathon, who were found living in deplorable conditions in May 2020.
The findings reveal that Kaleb and Jonathon, both diagnosed with significant global developmental delay and intellectual disabilities, missed numerous appointments with specialist services provided by Queensland Health from 2005 to 2020. The report notes that health care workers failed to consistently follow up on these missed appointments.
Despite previous reports to child protection services between 2000 and 2005, Queensland Health did not make additional referrals to Child Safety. The case has raised serious concerns about the missed opportunities to address potential child safety issues, particularly as the brothers were discovered in a state of severe malnutrition and locked in a room without clothing.
This alarming situation prompted an examination by the disability royal commission, which aimed to uncover the circumstances surrounding the violence, abuse, neglect, and violations of human rights the siblings endured during their formative years. The commission recommended that the Queensland government issue a formal apology for its failures in safeguarding the brothers, which was delivered in September 2023.
The ombudsman’s independent review assessed the roles and responsibilities of various departments and agencies involved with Kaleb, Jonathon, and their father, culminating in three reports, including one focused on Queensland Health, submitted on a Tuesday.
A prior report released in April 2025 to Education Queensland highlighted that staff at the special school attended by the siblings had nearly daily contact with them. The staff observed that Kaleb and Jonathon often lacked proper clothing and food, sometimes required bathing due to unpleasant odors, and exhibited concerning health issues, such as unusual bowel movements. While these observations were documented, only one report concerning student protection was forwarded to the child safety department.
Ombudsman Anthony Reilly’s findings indicated significant shortcomings within the health department, particularly regarding guidance for recognizing missed health appointments as potential signs of neglect. Additionally, the review revealed that Queensland Health had not ensured that its staff received regular and consistent training on child protection protocols.
In his response, Queensland Health’s director-general, David Rosengren, acknowledged the ongoing challenges related to information systems throughout the decentralized health service network. He assured that efforts would continue to advance the Digital Hospital Program, aiming to create a more sophisticated, digitally enabled health system.
The report also highlighted that nearly one in ten children have not attended outpatient appointments in recent years, a figure that exceeds the non-attendance rate for the general population, raising concerns among officials.
After being discovered, Kaleb and Jonathon, now in their twenties, received hospital treatment for severe malnutrition for two weeks before being transitioned into state care with support from the National Disability Insurance Scheme (NDIS).
During the preparation of the latest report, the ombudsman’s office met with the siblings and proposed 13 recommendations, including the implementation of regular audits for missed outpatient appointments and improvements in information management systems for health services. Another recommendation emphasized the need for staff to consult with child protection units when they identify concerns, advocating for this approach to become standard practice.
