Starving and virtually naked, two severely disabled brothers are found living in squalor with their dead father nearby as authorities finally come to their aid.
Almost six years after the shocking discovery, a key child safety advocate says missed opportunities for intervention were a regular occurrence.
However, Queensland Family and Child Commission Principal Commissioner Luke Twyford is hopeful a damning report sparks action from the state government.
The Queensland Ombudsman report detailed how the two boys - referred to as Kaleb and Jonathon - slipped through the department's cracks over two decades.
The severe abuse and neglect of the siblings sparked an independent review after their plight was highlighted at the 2023 national disability royal commission.
In May 2020 the boys were found by authorities in a bedroom with the door handles removed, in soiled nappies and with their dead father - their sole carer - in a nearby room.
A year earlier, one of the boys was witnessed gnawing on a dog bone when a public tip-off prompted a visit by authorities to their home.
The brothers were admitted to hospital and treated for severe malnutrition.
They suffered from significant developmental delays and intellectual disabilities, with limited verbal communication.
The Queensland Ombudsman report identified shortfalls in Queensland Health staff's ability to identify and respond to child protection concerns.
The report made 13 recommendations after investigating interactions over a 20-year period between state health staff and the boys, who are now in their early 20s and in state care.
Concerns about Kaleb's wellbeing were raised with child safety officers by Queensland Health staff shortly after his birth in 2000.
He spent significant periods of time in foster care in his first three years, with Queensland Health providing early childhood and paediatric care.
After Jonathon was born in 2003, Queensland Health made another report to Child Safety.
In 2005, Child Safety was notified again after Kaleb and Jonathon missed several health appointments, with staff concerned both boys were being neglected.
Child Safety investigated and found the concerns of neglect were substantiated.
But for the next 10 years, Queensland Health had little interaction with the boys or their father.
Staff failed to follow up their failure to attend specialist appointments, resulting in them being discharged with no further reports being made.
Among the recommendations, the report said Queensland Health needed to provide staff with clearer information about how to identify and respond to child protection concerns.
Staff needed clearer guidance on concepts such as cumulative harm, parent behaviour and neglect of medical care, the report found.
It also stressed the need for improvement of information management systems.
Mr Twyford, a leading advocate for child safety, described the siblings' plight as a tragic case.
"Unfortunately the missed opportunities for intervention that were revealed are occurring too regularly," he said.
"I welcome the ombudsman's reports into this matter and the recommendations, which must now spark action."
Mr Twyford, who also chairs the state's child death review board, said he continued to see gaps in how the disability, health, education and child safety systems responded to vulnerable children.
"All workers must be trained on their role in closing those gaps."
The board highlighted ongoing failures to respond to known risks, particularly for non-verbal children and kids with complex needs, he said.
"These issues are compounded by poor cross-agency coordination and barriers to timely support."
The ombudsman's report is the third and final in a series examining the multi-departmental failure to ensure the boys' safety and wellbeing.
The state education, housing and public works departments were criticised in previous reports following the royal commission, which described the boys' plight as torture.
The Queensland government delivered a formal apology in September 2023 after the boys' mistreatment came to light.
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