Two severely disabled brothers were found starving and naked near their dead father after authorities missed opportunities for years to raise concerns.
A damning Queensland Ombudsman report has been released detailing interactions over a 20-year period between state health staff and the two boys, referred to as Kaleb and Jonathon.
The boys suffered from significant developmental delays and intellectual disabilities, with limited verbal communication.
Kaleb and Jonathon were found unclothed and severely malnourished in a squalid room in May 2020.
Their father, who was also the boys' carer, was found dead in the same house.
Kaleb and Jonathon, who are now in their early 20s, were admitted to hospital and treated for severe malnutrition.
They are now in state care.
The report said Queensland Health staff had concerns for the boys' safety and wellbeing from birth.
The boys were born in 2000 and 2003, respectively.
In their early years, several child protection reports were made to the Department of Families, Seniors, Disability Services and Child Safety.
Staff did not always follow up on their failure to attend and no further reports were made to Child Safety.
The report made 13 recommendations, saying Queensland Health needed to provide staff with clearer information about how to identify and respond to child protection concerns.
It highlighted staff needed clearer guidance on concepts like cumulative harm, parent behaviour and neglect of medical care.
It also highlighted the need for improvement of information management systems.
The case was examined at the disability royal commission in 2023, looking at how and why the boys experienced violence, abuse and neglect.
The Queensland government delivered a formal apology for omissions in preventing harm the boys experienced in September 2023, as part of the commission's recommendations.
The ombudsman's report is the third in a series examining the multi-departmental failure to ensure the boys' safety and wellbeing.
Previous reports have criticised the Department of Education and Department of Housing and Public Works for their roles in the shocking case.
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