Margaret Nyland’s report, released today after cabinet met to discuss its contents, highlights “a system overwhelmed by the volume and complexity of work, with notifications received every day relating to children living in dire circumstances who desperately need someone to take action on their behalf… in many cases the response comes so late that there is little choice to do anything other than to remove the child from their family.”

However, despite Government speculation of a complete “re-write of the state’s child protection laws”, Nyland warns “the temptation to impose additional layers of policy and process to achieve sustainable change should be resisted”.

Instead, she wants what successive Governments perhaps feared most – substantial new investment.

“System change does not come from imposing more regulation on how the work is to be done; it comes from a greater investment in growing the knowledge base of workers, both at a planning and service delivery level,” the report states.

Jay Weatherill today committed $200 million budgeted over the next four years to begin addressing the demands, noting that some of the reforms would “require considerable work and consultation”.

“My Government accepts full responsibility for the failings of the state’s child protection system in keeping children safe,” he said.

“I am sorry for failing in this most fundamental duty to the children in our care.”

Fronting media, Weatherill said he was “sick at heart” about the litany of failures documented, but warned “protection of children has to be everybody’s business”.

“No single agency can begin to bear these responsibilities alone,” he said.

The Premier argued his Government was spending more than the national average per child on child protection measures, but conceded “we’re mot spending in the right place”.

He said there were now 3300 children in state care compared to a peak of 1200 when he was the minister responsible.

Nyland’s is the latest in a series of dissertations on the troubled agency Families SA, and its findings both endorse and reject a range of recommendations that have come before it.

Nyland calls for the implementation of the long-ignored Layton report demand for the establishment of a Children’s Commissioner – a demand that has been taken up by the State Opposition.

But she is less convinced about the call by state coroner Mark Johns, who last year concluded an inquiry into the death of Chloe Valentine, to examine a broadening of adoption provisions.

“The Commission is not persuaded that an increased emphasis on making children in care available for adoption is necessarily appropriate, when fundamental considerations of the child’s best interests are brought into account,” the report states.

The report, while emphasising the need to avoid “laying all the blame on the statutory agency”, is a major blow for the credibility of the Weatherill Government, suggesting many of its recent moves to repair the beleaguered agency have been counter-productive.

She also rejects a move publicly backed by the Premier to review the use of mandatory notifications, arguing: “The Commission is also not persuaded that legislative change would necessarily modify notifier behaviour… therefore, no change is proposed in mandatory notification duty.”

Nyland has already demanded the department be removed from the purview of Education – a move previously long-resisted by Weatherill himself.

Moreover, she suggests much-hyped moves to reform Families SA in the wake of the Shannon McCoole scandal were counter-productive.

“There is no doubt that the reform agenda identified was well aimed and necessary,” she writes.

“The way in which the reforms were developed and implemented, however, caused dissent and disquiet throughout all levels of the Agency, including the Families SA Executive.

“Overwhelmingly the message was that workers felt shut out, silenced and disrespected. The process was the source of a great deal of ill feeling across the Agency [and] the Redesign process further disengaged front-line child protection staff and devalued the contribution of professional staff in the Agency.”

“It is apparent that the processes adopted further alienated the workforce and exacerbated an already toxic state of affairs.”

Nyland called on the Government to review the conduct of the “specific staff” involved in overseeing McCoole’s employment, “and consider their ongoing suitability for employment in their role”.

Child Protection Reform minister John Rau said those in question had already been suspended “pending an investigation”, which “might involve others as well”.

A recurring theme in the commission’s findings is funding – or lack thereof.

She notes that “a number of recommendations” of the Layton review were “stymied” by a lack of funding, and argues that previous structural redesigns fell foul of being implemented within the existing budget.

Nyland calls for an overhaul of “unsatisfactory rotational care”, noting: “As reliance on rotational forms of care has grown in this state, the costs of alternative care have grown to soak up more than 70 per cent of the overall child protection budget.”

“This leaves little to invest in prevention and early intervention strategies to stop children entering the child protection system in the first place,” she says.

The report demands “wholesale reform of residential care”, with a streamed model to replace “all other forms of residential care being delivered”.

This would include facilities for short-term assessment, as well as for children with high or complex needs. This would not house children aged under 10, nor more than four children in any one facility at one time.

Facilities currently cater for up to 12 children.

“Large units do not provide the homely environment that children need, and the warehousing of a large number of children with complex behaviours under one roof inevitably leads to residents learning new behaviours from each other,” Nyland argues.

“It creates an unsafe living environment.”

The existing residential care units would be closed.

Single-handed shifts by residential care workers should also be abandoned, the report found – a move that could have prevented the abuse by Shannon McCoole that prompted the commission’s review.

Child development minister Susan Close said this would be immediately instituted for commercial care, but would take significantly longer to implement in Government facilities, requiring “not only substantial resources but substantial staff”.

Close described the child protection system as “overwhelmed and underperforming”, with “a lack of capacity to ensure effective intervention services”.

Among other areas in dire need of improvement, Nyland highlights the over-burdened and under-staffed Child Abuse Report Line – “the subject of constant complaint, primarily due to the unreasonably long waiting times imposed on people who are trying to make a report about a child protection matter”.

Implementation of a referral pathway should reduce the demand on the statutory agency and early intervention services should, over time, limit the cycle of notification and re-notification.

But again, she rejects the “perception that some of the overload of work at CARL is due to unnecessary reports”.

“To the contrary, many notifications screened out as not warranting a response revealed children left in unacceptable circumstances in which they needed help,” she writes.

She also warns against reliance on electronic notifications, instead urging authorities to restrict access to the eCARL service “to notifiers who have completed mandated notifier training”.

Instead, Nyland recommends an unequivocal investment “in the professional development of the Agency’s Call Centre practitioners”, with new benchmarks imposed to ensure a maximum waiting time of 30 minutes, no more than two hours wait for a callback and 24 hours to assess any given notification.

The Call Centre should never be left unattended, she states, and telephone calls from notifiers must only be taken by “degree-level, tertiary qualified and experienced practitioners”.

Moreover, Crisis Care staffing levels should be immediately increased to no fewer than three staff at each shift.

Nyland also proposes the establishment of a cross-departmental Early Intervention Research Directorate, responsible for creating and coordinating a five-yearly whole of government prevention and early intervention strategy to “guide funding priorities and enable greater coordination of services in each local area”.

Families SA – or the department that replaces it – will contain a new human resources unit to overhaul the process by which staff are hired and skilled.

There will be legislative changes required to enable greater information-sharing between agencies and co-ordinate decision-making.

“Child protection is not a problem with an easily identifiable ‘fix’ or an end point at which the problem can be assessed as solved,” Nyland writes.

“The best that can be hoped for is that the proposed reforms improve the system and mark the start of a process of continuous evaluation and improvement.”