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Policy No.:  D0234  

 
 

Child Protection   
Mandatory Reporting of 

Suspicion that a Child or 
Young Person (0 - under 

18 years) is or may be 
at Risk of Harm 
Policy Directive 

 
 
 

Version No.:  4 
Approval date: 4/11/2020 

 

 
 
 
 
 
 
 
 
 
 

  



 
 
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Contents  
 
1. Policy Statement ................................................................................................................ 3 

2. Roles and Responsibilities ................................................................................................. 3 

3. Policy Requirements .......................................................................................................... 5 

4. Implementation &amp; Monitoring ............................................................................................ 10 

5. National Safety and Quality Health Service Standards .................................................... 10 

6. Definitions......................................................................................................................... 11 

7. Associated Policy Directives / Policy Guidelines and Resources ..................................... 13 

8. Document Ownership &amp; History ....................................................................................... 14 



 
 
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Child Protection   Mandatory Reporting of Suspicion 
that a Child or Young Person (0   under 18 years) is 
or may be at Risk of Harm Policy Directive 
 

1. Policy Statement 

The purpose of the Child Protection   Mandatory Reporting of Suspicion that a Child or Young 
Person (0 - under 18 years) is or may be at Risk of Harm Policy Directive is to ensure a consistent 
approach to the mandatory reporting requirements relating to suspicion that a child or young 
person is or may be at risk of harm in accordance with the Children and Young People (Safety) Act 
2017.  
 
Under Section 31(1) of the Children and Young People (Safety) Act 2017, if a person suspects on 

reasonable grounds that a child or young person is, or may be, at risk of harm, and that suspicion 
was formed in the course of the person s employment (whether paid or voluntary), they must report 
that suspicion as soon as is reasonably practicable after forming the suspicion. 
 
Under Section 31(3), a person may (but need not), if the person suspects on reasonable grounds 
that the physical or psychological development of an unborn child is at risk (whether due to an act 
or omission of the mother or otherwise) and that suspicion was formed in the course of the 
person s employment, report that suspicion. 
 
With the implementation of this policy directive (this directive) SA Health will ensure:  

? All suspicions that a child or young person is, or may be, at risk of harm are reported as soon 
as is reasonably practicable after forming the suspicion.  

? Systems are in place to assist staff in the identification of risk.  

? Staff are aware of their legal obligations to report their suspicion that a child or young person 
is or may be at risk of harm. 

 
The requirements of this directive are in addition to the duty of all SA Health staff (employees, 
volunteers, students on placement or work experience, contractors and consultants) who provide 
health services to children and young people to safeguard and promote the outcome that children 
and young people be kept safe from harm. 
 
This directive forms part of SA Health s broader framework to ensure the health, wellbeing, safety 
and protection of children and young people. This directive must be read and administered in 
conjunction with the Child Safe Environments (Child Protection) Policy Directive, Responding to 
Suspected or Alleged Offences against a Child or Young Person Occurring at a SA Health Facility 
or Service Policy Guideline, and the Information Sharing Guidelines for Promoting Safety and 
Wellbeing SA Health ISG Appendix Policy Directive.  
 

2. Roles and Responsibilities 
 
Scope 

This directive applies to all SA Health staff (including volunteers) providing services directly or 
indirectly to pregnant women, children or young people who form a reasonable suspicion in the 
course of their employment that a child (born or unborn) or young person is, or may be, at risk of 
harm. For the purpose of this directive the use of the word child (born or unborn) or young person 
refers to a person who is under 18 years of age. 
 
2.1 Chief Executive, SA Health is responsible for: 

? ensuring the safety and welfare of all children in the care of SA Health; 









 
 
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? ensuring the reporting of suspicion that a child (born or unborn) or young person is, or may 
be, at risk of harm is in accordance with this directive. 

 
2.2 Local Health Network (LHN) Governing Boards are responsible for: 

? governance and oversight and ensuring effective clinical and corporate governance 
frameworks are in place for LHNs to comply with this directive. 

 
2.3 Local Health Network and SA Ambulance Services Chief Executive Officers will: 

? ensure staff (including volunteers) are aware of their legal obligations to report a suspicion 
that a child (born or unborn) or young person is, or may be, at risk of harm in accordance 
with this directive;  

? ensure systems are in place to assist staff in the identification of child abuse and / or 
neglect; 

? ensure the development of local protocols and procedures as required to support this 
directive; 

? ensure staff (including volunteers) receive appropriate Child Safe Environments training 
and information. 

 
2.4 Executive Directors, Directors and other Senior Managers will: 

? develop, implement and monitor local protocols and procedures that ensure staff (including 
volunteers) respond to suspicion that a child (born or unborn) or young person is, or may 
be, at risk of harm;   

? ensure staff (including volunteers) report their suspicion that a child (born or unborn) or 
young person is, or may be, at risk of harm in accordance with this directive;  

? ensure staff (including volunteers) access and complete appropriate Child Safe 
Environments training and information.  

 
2.5 All SA Health staff (including volunteers) will: 

? be aware of their legal obligations to report a suspicion that a child (born or unborn) or 
young person is, or may be, at risk of harm in accordance with this directive by doing one or 
more of the following: 
o making a telephone notification / report to the Child Abuse Report Line (CARL); 

o making an electronic notification / report on the eCARL electronic reporting system; 

o in each case providing: in the case of an unborn child - the name and address (if 
known) of the mother of the unborn child; in any other case - the name and address (if 
known) of the child or young person; information setting out the grounds for the 
person s suspicion; and such other information as the person may wish to provide in 
relation to their suspicion; 

o and, in each case, completing the Record of Mandatory Notification for Suspected 
Child Abuse or Neglect (MR-MNR) and placing this form in the child s or young 
person s health record for future reference; 

? act to ensure the safety and wellbeing of children and young people in the care of SA 
Health. 

 
2.6 In addition to their responsibilities in 2.5, all Local Health Network and SA Ambulance 
Service staff (including volunteers) will also: 

? complete Child Safe Environments training (that incorporates mandatory reporting 
requirements) 

  



 
 
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3. Policy Requirements 
 
3.1 Collaboration and Information Sharing  

? Staff will operate in accordance with the Information Sharing Guidelines for Promoting 
Safety and Wellbeing (ISG) and the Information Sharing Guidelines for Promoting Safety 
and Wellbeing SA Health ISG Appendix Policy Directive. 

 
3.2 Reporting Authority  

? The Department for Child Protection (DCP) is the administrative unit of the Public Service 
specified by the Minister by notice in the Gazette for the Children and Young People 
(Safety) Act 2017. 

? DCP, through the Child Abuse Report Line (CARL), is to be notified as soon as practicable 
of any suspicion on reasonable grounds that a child (born or unborn) or young person is, or 
may be, at risk of harm and the suspicion was formed in the course of the person's 
employment. 

? Mandated reporters may also use the eCARL electronic reporting system to report 
suspicions that a child (born or unborn) or young person is, or may be, at risk of harm. To 
make an online report, staff are required to register and login to the online child protection 
reporting system. See the instructions for using the online child protection reporting system. 

 
3.3 Mandated Reporters 

Under Section 31 of the Children and Young People (Safety) Act 2017 certain people (mandated 
reporters) must notify DCP if they suspect on reasonable grounds that a child or young person is, 
or may be, at risk of harm and the suspicion is formed in the course of the person s employment. 
The person must notify DCP of that suspicion as soon as practicable after he or she forms the 
suspicion. 
 
Mandated reporters under Section 30(3) are:  

(a) prescribed health practitioners;  

(b) police officers;  

(c) community corrections officers under the Correctional Services Act 1982;  

(d) social workers;  

(e) ministers of religion;  

(f) employees of, or volunteers in, an organisation formed for religious or spiritual purposes;  

(g) teachers employed as such in a school or a pre-school or kindergarten; 

(h) employees of, or volunteers in, an organisation that provides health, welfare, education, 
sporting or recreational, child care or residential services wholly or partly for children and 
young people, being a person who   
(i) provides such services directly to children and young people; or  

(ii) holds a management position in the organisation the duties of which include direct 
responsibility for, or direct supervision of, the provision of those services to children 
and young people;  

 
A reference to a person being employed will be taken to include a reference to a person who:  

(a) is a self-employed person;  

(b) carries out work under a contract for services; 

(c) carries out work as a minister of religion or as part of the duties of a religious or spiritual 
vocation;  

(d) undertakes practical training as part of an educational or vocational course eg students 
on placement;  

(e) carries out work as a volunteer.  








 
 
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A prescribed health practitioner refers to:  

(a) medical practitioners;  

(b) pharmacists;  

(c) registered or enrolled nurses;  

(d) dentists;  

(e) psychologists. 
 
3.4 A mandated reporter reports a suspicion by doing one or more of the following:  

? making a telephone notification / report to the Child Abuse Report Line (CARL); 

? making an electronic notification / report on the eCARL electronic reporting system; 

? and, in each case, providing: 
o in the case of an unborn child - the name and address (if known) of the mother of the 

unborn child;  
o in any other case - the name and address (if known) of the child or young person; 
o information setting out the grounds for the person's suspicion;  
o such other information as the person may wish to provide in relation to their suspicion; 

? and, in each case, completing the Record of Mandatory Notification for Suspected Child 
Abuse or Neglect (MR-MNR) and placing this form in the child s or young person s health 
record for future reference.  

 
Mandated reporters are not required to report / notify: 

? if the person believes on reasonable grounds that another person has reported the matter; 
or 

? if the person's suspicion was due solely to having been informed of the circumstances that 
gave rise to the suspicion by a police officer or child protection officer acting in the course 
of their official duties; or 

? if the person believes on reasonable grounds that DCP is already aware of all of the 
information that forms the basis of the person s suspicion. 

Should SA Health staff become aware of new or additional information that forms a suspicion 
that the child or young person is, or may be at risk of harm, a new report must be made. 

All SA Health staff (including volunteers) have a responsibility to ensure children and young 
people are kept safe from harm, and all SA Health staff not described as a mandated reporter 
(refer to 3.3), are encouraged to report DCP through CARL or eCARL if they suspect a child 
presenting at health services or facilities has been, or is at risk of, harm. 

 
3.5 Rights and Responsibilities of Mandated Reporters 

? It is the individual s personal responsibility to report their suspicion that a child or young 
person is, or may be, at risk of harm to DCP. 

? Reporters must make their own report when they have additional knowledge of a child or 
young person s situation beyond that provided to them by another mandated reporter or 
police officer who confirms a report has been made.  

? The threshold for reporting is reasonable suspicion, not actual proof of harm. 

? A mandated reporter does not exhaust their duty of care to a child or young person by 
making a notification. SA Health staff must take such action as is necessary at the time to 
protect a child or young person and prevent further harm at the time if it is safe to do so. 

? SA Health staff who are mandated reporters must ensure they have completed Child Safe 
Environments training and consider the necessity of being registered to access the online 



 
 
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child protection reporting system. When registered for online reporting, SA Health staff 
must be familiar with the instructions for using the online child protection reporting system.  

3.6 Confidentiality  

Under Section 163 of the Act, the identity of a person who has made a report will not be 
disclosed to any other person unless the disclosure: 

? is made with the consent of the person who gave the notification; or 

? is required or authorised by the Chief Executive of DCP or under this Act; or 

? is made by way of evidence and the court or tribunal is satisfied the disclosure is of critical 
importance in the proceedings and failure to admit it would prejudice the proper 
administration of justice. 

? is reasonably necessary for the performance of the person s official functions and duties, 
or the functions and duties of a State authority relating to the protection of children and 
young people from harm, or 

? is reasonably necessary to prevent harm, or further harm, being caused to a child or 
young person to whom the information relates. 

 
3.7 When to Report 

3.7.1 SA Health staff and volunteers must report their concerns to DCP as soon as practicable 
after their suspicion is formed through CARL or eCARL when:  

? the person suspects on reasonable grounds that a child (born or unborn) or young 
person is or may be at risk of harm;  

? that suspicion was formed in the course of the person's employment; 

? they have additional information about a child s situation that forms a suspicion 
beyond that provided to them by another mandated reporter or police officer acting 
in the course of their official duties; 

? unborn child notifications   it is recommended that reports relating to an unborn 
child are made when a clinician reasonably suspects that the unborn child is at risk. 
For example, in the event that SA Health becomes aware that a parent or guardian 
has previously committed serious offences against a child in their care ( qualifying 
offences ), or the mother is an existing client of DCP, or has had a previous child 
removed. 

 
3.7.2 Reasonable grounds to report suspicions of harm may include (but are not limited to):  

? when a child states they have been harmed; 

? observations of child behaviour and / or injuries lead to suspicion of harm; 

? observations of a particular parent / carer or others  behaviours lead to suspicion; 

? when a child states they know of someone or a friend who has been harmed. They 
may be referring to themselves. 

 
3.7.3 For more information regarding what must and must not be reported refer to the DCP 

website https://www.childprotection.sa.gov.au/. 
 

3.7.4 Failure to report a suspicion may incur a maximum penalty of $10 000.  
See Section 31 of the Children and Young People (Safety) Act 2017. 

 
3.8 How to Report 

DCP is responsible for operating the Child Abuse Report Line (CARL) in South Australia. 
CARL is a 24 hour centralised point of intake and all child protection concerns are to be 





 
 
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reported for assessment. To report a suspicion that a child or young person is or may be at 
risk, contact CARL. Reports to CARL can be made by telephoning 131 478.  

An eCARL report can also be made for less serious concerns, in matters where an urgent 
response is not required.  To access eCARL go to: www.reportchildabuse.sa.gov.au. To make 
an eCARL report, you must register and login to the electronic reporting system via online 
child protection reporting system. 

All serious or urgent concerns must be reported to CARL and must not be submitted to 
eCARL. Serious or urgent concerns include concerns about an infant (under 12 months) with 
any injuries; when a child is in the care of SA Health and it is suspected that they are being or 
may be at risk of harm; or when there is reasonable suspicion that a child or infant is in 
imminent or immediate danger or at high risk of serious harm or serious injury. 

 
3.9 Information Required 

When making a notification to CARL either by telephone, or electronically through eCARL, the 
person making the report must provide the following information.  

This information is to be documented on the Record of Mandatory Notification for Suspected 
Child Abuse or Neglect (MR-MNR) and placed in the child s or young person s health record 
for future reference (refer to 3.10).  

3.9.1 Identification Details: 

? child s name, date of birth, age and address, or expected delivery date if unborn 
child notification;  

? whether the child is Aboriginal or Torres Strait Islander, and Clan group if known; 

? comprehensive description of injury, abuse and / or neglect (current and previous); 

? the child s current situation and location; 

? name, date of birth, address and phone number of parent, caregiver and alleged 
perpetrator, current whereabouts and any relevant known history; 

You will be asked more detailed questions when you contact CARL. 

3.9.2 Reporter Details: 

? name, job title, unit / designation, agency name and contact number;  

? are you currently working with the child or the family, and if so, in what capacity; 

? type and frequency of contact with the family and the last time you saw the child;  

? whether there are any known worker safety issues; 

? what response you are expecting from DCP. 

3.9.3 Specific Details of the Concern:  

? what leads you to be concerned - what did you see or hear, and when?; when and 
how did you find out about the harm?; who else is aware of these concerns?; 

? what has the child disclosed - what did they say and what was their emotional 
presentation?; 

? description of the behaviour displayed by the child that is of concern; 

? description of any caregiver behaviour that is of concern, including how often and 
how severe; 

? size and location of injuries, if any, with descriptions of bruising (ie colour and 
appearance); 






 
 
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? has the child been seen by a Doctor? If so, provide the Doctor s name and contact 
number; 

? has the matter been reported to Police? If so, provide Police reference number;  

? if you are reporting a domestic violence incident, has there been previous contact 
with the family or the alleged perpetrator regarding the issue (if known); 

? if you are reporting problem sexual behaviour, details of the behaviour are required - 
type, context, frequency, responses to behaviour (parents, school, parent s 
understanding of the behaviour, family attitudes to sexuality, appreciation of child s 
possible disability); 

? what is known about the functioning of the family (domestic violence, substance 
misuse, homelessness, violence to people outside the family, relevant health 
factors, mental health problems, physical or intellectual disability); 

? are there any known chronic or acute issues impacting the child (neglect, physical, 
sexual, emotional abuse, lack of caregiving); 

? are there any known protective factors for the care and protection of the child 
(extended family or other support networks, child care arrangements, nature of 
involvement with any agencies); 

? whether the parent / caregiver and / or perpetrator is aware of the notification (and 
what are the safety implications). 

Note: SA Health staff may not have all of this information before making a report. However, 
providing more comprehensive information to CARL will better inform the response to the 
child protection concerns.  

 
3.10 Health Record Documentation of Report 

? The Record of Mandatory Notification for Suspected Child Abuse or Neglect (MR-

MNR) is to be completed by all SA Health staff when reporting mandatory notifications to 
DCP through CARL or eCARL for suspected child abuse or neglect. The form is to be 
signed and placed in the child s or young person s health record for future reference; or if 
there is no child or young person s health record, then in the relevant adult health record. 

? When there is a Freedom of Information (FOI) request, the identity of a mandated 

reporter will be maintained in confidence and not identified. Health records staff must 
ensure that the identity of the person who made the report is redacted from the record. 
Where a mandatory notification is made (and the reporter name redacted) but the content 
could still identify the person making the report (eg country teams where only one staff has 
been the contact) then sections of the form related to the whole notification may be 
redacted if there is a FOI request by the consumer. 

? Details about notifications made may be accessed in situations where there is a subpoena 
or warrant. 

 
3.11 Process and Outcome of Report 

? DCP will provide feedback to mandated reporters on whether their concerns are going to be 
recorded as "child protection" or otherwise. 

? Other feedback may be provided by contacting the responsible DCP office and will 
principally be determined by the mandated reporter s ongoing role with the child or young 
person. 

? SA Health staff are required to document any interactions or discussion with DCP in the 
child or young person s health record. 

  




 
 
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4. Implementation &amp; Monitoring 
 
SA Health will ensure in the implementation of this directive that: 

? SA Health staff and volunteers are aware of the directive and undertake Child Safe 
Environments training;  

? should staff and volunteers form a suspicion that a child or young person is, or may be, at risk 
of harm the concerns will be reported to DCP as soon as practicable after the suspicion has 
been formed; 

? systems are in place to assist staff in the identification of risk; 

? staff and volunteers are aware of their legal obligation to report their suspicion a child or young 
person is, or may be at risk of harm; 

? staff and volunteers are knowledgeable about the operation of the requirement to report a 
suspicion that a child or young person is, or may be, at risk of harm.  

 
Compliance will be monitored by Local Health Networks (LHN) and SA Ambulance Services 
(SAAS) by: 

? identifying and reviewing the Safety Learning System incident reports concerning children 
and young people. These reports will be assessed annually or as required by LHN Risk 
Management / Patient Safety Units; 

? monitoring LHN and SAAS staff completion of the mandatory Child Safe Environments 
training - number of staff (including volunteers) attending and completing Child Safe 
Environments training. 

 
Child Safe Environments compliance and regulation is managed by the Department for Human 
Services.  
 

5. National Safety and Quality Health Service Standards 
 
The Australian Commission on Safety and Quality in Health Care has developed the National 
Safety and Quality Health Service Standards (the Standards). 
 
The Standards provide a nationally consistent and uniform set of measures of safety and quality 
for application across a wide variety of health care services. They propose evidence-based 
improvement strategies to deal with gaps between current and best practice outcomes that affect a 
large number of patients. 
 

 
  

 
 

National Standard 
1 
 

Clinical 
Governance 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 

 
 
 

 
 

National 
Standard 3 

 
Preventing &amp; 
Controlling 
Healthcare- 
Associated 
Infection 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Comprehensiv

e Care 
 
 

 
 

National 
Standard 6 

 
Communica

ting for 
Safety 

 
 
 
 

 
 

National 
Standard 7 

 
Blood 

Management 

 
 

National 
Standard 8 

 
Recognising &amp; 
Responding to 

Acute 
Deterioration 

 
 

? ? ? ? ? ? ? ? 





















































 
 
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6. Definitions 
 
In the context of this document: 
 
Aboriginal Child or Young Person refers to a child or young person who is a descendant of the 
indigenous inhabitants of Australia; and regards themself as Aboriginal or, if they are a young 
child, is regarded as Aboriginal by at least one of their parents. 
 
Child or Young Person refers to a person under 18 years of age. 
 
Duty of Care is a common law concept that refers to the responsibility of employees and 
volunteers to provide children (born or unborn) and young people with an adequate level of 
protection against harm. 
 
eCARL is the DCP electronic child protection reporting system used to report less serious, non-
urgent or non-imminent concerns. Information about eCARL can be accessed at 
www.reportchildabuse.sa.gov.au. To make a report online you must register and login to the online 
child protection reporting system. 
 
Health Record includes a patient s medical record, patient / client record, case note and patient / 
client file. 
 
Mandated Reporter refers to a person who under the Children and Young People (Safety) Act 
2017 Section 30 (3) (4) (5) is required to report any suspicion that a child is, or may be, at risk of 
harm to DCP. This applies to suspicion occurring in the course of their employment, and applies to: 

(a) prescribed health practitioners;  

(b) police officers; 

(c) community corrections officers under the Correctional Services Act 1982;  

(d) social workers;  

(e) ministers of religion;  

(f) employees of, or volunteers in, an organisation formed for religious or spiritual purposes;  

(g) teachers employed as such in a school (within the meaning of the Education and Early 
Childhood Services (Registration and Standards) Act 2011) or a pre-school or 
kindergarten;  

(h) employees of, or volunteers in, an organisation that provides health, welfare, education, 
sporting or recreational, child care or residential services wholly or partly for children and 
young people, being a person who  

(i) provides such services directly to children and young people; or 

(ii) holds a management position in the organisation the duties of which include direct 
responsibility for, or direct supervision of, the provision of those services to children 
and young people;  

(i) any other person of a class prescribed by the regulations for the purposes of this 
subsection. (See information on Regulation 9 below). 

 
A reference to a person being employed will be taken to include a reference to a person who:  

(a) is a self-employed person;   

(b) carries out work under a contract for services;  

(c) carries out work as a minister of religion or as part of the duties of a religious or spiritual 
vocation;   

(d) undertakes practical training as part of an educational or vocational course;   

(e) carries out work as a volunteer.  
 
 






 
 
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A prescribed health practitioner refers to:  

(a) medical practitioners;   

(b) pharmacists;   

(c) registered or enrolled nurses; 

(d) dentists;  

(e) psychologists.  
 
Meaning of Harm in relation to a child or young person in accordance with the Children and 
Young People (Safety) Act 2017: 

17(1) A reference to harm will be taken to be a reference to physical harm or 
psychological harm (whether caused by an act or omission) and, without limiting the 
generality of this subsection, includes such harm caused by sexual, physical, mental 
or emotional abuse or neglect.  

17(2) Psychological harm does not include emotional reactions such as distress, grief, 
fear or anger that are a response to the ordinary vicissitudes of life.  

 
Meaning of At Risk in relation to a child or young person in accordance with the Children and 
Young People (Safety) Act 2017: 
(1) A child or young person will be taken to be at risk if:  

(a) the child or young person has suffered harm (being harm of a kind against which a child or 
young person is ordinarily protected); or  

(b) there is likelihood that the child or young person will suffer harm (being harm of a kind 
against which a child or young person is ordinarily protected); or  

(c) there is likelihood that the child or young person will be removed from the State (whether by 
their parent or guardian or by some other person) for the purpose of   

(i) being subjected to a medical or other procedure that would be unlawful if performed 
in this State (including, to avoid doubt, female genital mutilation); or  

(ii) taking part in a marriage ceremony (however described) that would be a void 
marriage, or would otherwise be an invalid marriage, under the Marriage Act 1972 of 

the Commonwealth; or  

(iii) enabling the child or young person to take part in an activity, or an action to be taken 
in respect of the child or young person, that would, if it occurred in this State, 
constitute an offence against the Criminal Law Consolidation Act 1935 or the Criminal 

Code of the Commonwealth; or  

(d) the parents or guardians of the child or young person  

(i) are unable or unwilling to care for the child or young person; or  

(ii) have abandoned the child or young person, or cannot, after reasonable inquiry, be 
found; or  

(iii) are dead; or  

(e) the child or young person is of compulsory school age but has been persistently absent 
from school without satisfactory explanation of the absence; or  

(f) the child or young person is of no fixed address; or  

(g) any other circumstances of a kind prescribed by the regulations exist in relation to the child 
or young person.  

(2) It is immaterial for the purposes of this Act that any conduct referred to in subsection (1) took 
place wholly or partly outside this State.  

(3) In assessing whether there is likelihood that a child or young person will suffer harm, regard 
must be had to not only the current circumstances of their care but also the history of their 
care and the likely cumulative effect on the child or young person of that history.  

(4) In this section  female genital mutilation means   

(a) clitoridectomy; or  



 
 
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UNOFFICIAL 

(b) excision of any other part of the female genital organs; or  

(c) a procedure to narrow or close the vaginal opening; or  

(d) any other mutilation of the female genital organs, but does not include a sexual 
reassignment procedure or a medical procedure that has a genuine therapeutic purpose; 
sexual reassignment procedure means a surgical procedure to give a female, or a person 
whose sex is ambivalent, genital characteristics, or ostensible genital characteristics, of a 
male.  

(5) A medical procedure has a genuine therapeutic purpose only if directed at curing or alleviating 
a physiological disability or physical abnormality. 

 
Qualifying Offences refers to any of the following offences (whether committed before or after the 
commencement of this Part of the Act) where the victim was a child and the offender was a parent 
or guardian of the child or young person:  

(a) murder;  

(b) manslaughter;  

(c) an offence against section 14 of the Criminal Law Consolidation Act 1935 (criminal 
neglect);  

(d) an offence against section 23 of the Criminal Law Consolidation Act 1935 (causing serious 
harm);  

(e) an offence against section 29 (1) or (2) of the Criminal Law Consolidation Act 1935 (acts 
endangering life or creating risk of serious harm);  

(f) an offence constituted of an attempt to commit an offence referred to in a preceding  
paragraph;  

(g) an offence under the law of another jurisdiction that corresponds to an offence referred to in 
a preceding paragraph. 

 
Record of Mandatory Notification for Suspected Child Abuse or Neglect (MR-MNR) is the 
form that is to be completed by all SA Health staff when reporting mandatory notifications to DCP 
through CARL or eCARL for suspected child abuse or neglect. This form is available to order 
through the Oracle Corporate System using Oracle number 19045571. 
 
Staff refers to all SA Health employees, volunteers, students on placement or work experience, 
contractors and consultants who provide services to the community or who have access to 
children s and young people s health records, including SA Health staff members working in other 
government agencies.  
 
The Patient Incident Management and Open Disclosure Policy Directive describes a 

standardised system for managing patient incidents that ensures all staff use the SA Health 
incident management reporting system Safety Learning System (SLS) for reporting and 
documenting the management and open disclosure of patient incidents. A patient incident is any 
event or circumstance which could have (near miss) or did lead to unintended and / or 
unnecessary psychological or physical harm to a patient, that occurs during an episode of health 
care. All patient incidents must be reported into the patient incident module of the SLS, via the 
online web form, within 24 hours or as soon as practicable. 
 

7. Associated Policy Directives / Policy Guidelines and Resources 

? Children and Young People (Safety) Act (SA) 2017 

? Child Safe Environments (Child Protection) Policy Directive 

? Child Safe Environments: Guidelines for mandated reporters and information for 
organisations 

? Child Safety (Prohibited Persons) Act 2016 

? Children and Adolescents in Adult Health Services Policy Guideline  










 
 
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UNOFFICIAL 

? Collaborative Case Management of 'At Risk' Infants in Hospitals Policy Directive 

? Collaborative Case Management of  At Risk  Infants in Birthing Hospitals Policy Guideline 

? Freedom of Information Act (SA) 1991 

? Information Sharing Guidelines for Promoting Safety and Wellbeing (ISG)  

? Information Sharing Guidelines for Promoting Safety and Wellbeing SA Health ISG 
Appendix Policy Directive 

? Interagency Code of Practice: Investigation of suspected child abuse and neglect (ICP) 

? Mandatory Reporting Guide South Australia 

? Multi Agency Protection Service (MAPS) Policy Directive 

? Multi Agency Protection Service (MAPS) Policy Guideline 

? National Association for Prevention of Child Abuse and Neglect (NAPCAN) 

? National Framework for Protecting Australia s Children: 2009-2020: Protecting children is 
everyone s business (Council of Australian Governments) 

? Responding to Suspected or Alleged Offences against a Child Occurring at a SA Health 
Facility and/or Service Policy Guideline 

? Reporting and Management of Incidents of Suspected or Alleged Sexual Assault of an 
Adult, or Sexual Misconduct by an Adult, within SA Health Facilities 

 
 

8. Document Ownership &amp; History 

Approval 
Date 

Version Who approved New/Revised Version Reason for Change 

4/11/2020 V4 
CEO, Women s and Children s Health 
Network 

Minor amendments to include new 
Mandatory Notification Record 

16/05/19 V3.1 
Director Corporate Governance and 
Policy 

Minor amendments in line with 
governance changes 

19/10/18 V3 SA Health Policy Committee Reviewed in line with legislative change  

09/02/15 V2 SA Health Portfolio Executive PE Approved version. 

01/09/14 V1.1 
Project Officer, Service Development 
Branch, Policy and Commissioning 

Formally reviewed in line with 1-5 year 
scheduled timeline for review. 

16/06/11 V1 SA Health Portfolio Executive Original PE approved version. 

 

Document developed by:  Corporate Affairs, DHW / Child Safety Strategy, WCHN 

File / Objective No.: 2014-10022/1 

Next review due:   4 November 2023 

Policy history: Is this a new policy (V1)?  N 

 Does this policy amend or update and existing policy?   Y  

 If so, which version? V3.1 

 Does this policy replace another policy with a different title?  N 

 If so, which policy (title)?  
 

ISBN:                                     978-1-76083-337-4 

 



















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