A 12-year-old girl charged with a stabbing murder had been repeatedly failed as she was shunted from place to place in Victoria's child protection system.
The girl, referred to as WD for legal reasons, was accused of stabbing a 37-year-old woman to death in the inner-western Melbourne suburb of Footscray in November 2023.
Prosecutors withdrew the charge in May, citing a lack of reasonable prospects of conviction under the presumption of doli incapax.
Doli incapax is a legal principle that a child younger than 13 is incapable of understanding the wrongfulness of their actions and therefore cannot be convicted of a crime.
The Victorian Commissioner for Children and Young People launched an investigation into the case as WD had been in out-of-home care for years.
In the commission's annual report, tabled in state parliament on Thursday, principal commissioner Liana Buchanan said the case exposed some of the most "profound service system failures" she had seen.
"At every stage of WD's childhood, opportunities were missed to disrupt the ever-increasing risk to which WD was exposed, and that she posed to herself and others," the report found.
"Simply put, systems - including the out-of-home care, mental health, disability support, policing and justice systems - did not meet her needs."
WD spent three years being moved through 10 different "contingency care" placements, designed to act as emergency accommodation, at a cost of $3 million.
The commission said the placements were inappropriate and unsafe and led to disruption of the girl's schooling and access to support.
She was reported missing hundreds of times, sometimes for days at a time, before her arrest.
Efforts to respond to her absences were ineffective and "at times appeared to be impacted by service fatigue, desensitisation and a lack of clear, co-ordinated action between Victoria Police, child protection and care providers".
"There were many different case managers and workers who were very, very busy trying to protect this child over that three-year period," Ms Buchanan told AAP.
"But none of it was effective, the efforts were very fragmented and there needed to be some significant escalation to bring together all of the agencies.
"That didn't happen."
In a first, the commissioner shared the inquiry's findings with Premier Jacinta Allan in a bid to spark change and shine a spotlight on the "invisible" issue.
"I can't change what happened in the past for this child," Ms Buchanan said.
"My interest really was to try and make sure, given the pretty devastating failings in this child's experiences, that we as a collective use these findings to really drive some urgent action."
She made 19 recommendations, including improving the department's oversight of and reliance on contingency placements.
Other suggestions were co-ordinated, cross-agency responses to child sexual exploitation, not relying as much on children to make formal statements to trigger a response, and greater access to forensic medical examinations for children with complex trauma and disability.
Children Minister Lizzie Blandthorn refused to discuss the details of WD's case but said contingency care placements were rare.
"Since we've been in government, we have been driving down contingency care placements," she told reporters at parliament.
"We have one at the moment."
She acknowledged services could work better but would not be drawn on who, if anybody, would be held accountable for the systemic failures WD suffered.
The commissioner has not received a formal response to the inquiry's recommendations from the Allan government after it was handed the report two months ago.
Ms Buchanan said the department had "drastically reduced" the use of contingency care placements since the end of 2023, but she was not aware that was in direct response to WD's case.
Across 2023/24, the commission recorded 1892 notifications of alleged child abuse and child-related misconduct by workers and volunteers, up 30 per cent from 2022/23.
There were another 43 children who died within 12 months of their last involvement with child protection, including eight Aboriginal children.
Lifeline 13 11 14
Kids Helpline 1800 55 1800 (for people aged 5 to 25)
1800 RESPECT (1800 737 732)
National Sexual Abuse and Redress Support Service 1800 211 028
