A 12-year-old girl charged with a stabbing has been repeatedly thwarted as she has been shuttled from place to place in Victoria’s child protection system.

The girl, named WD for legal reasons, was accused of stabbing to death a 37-year-old woman in Melbourne’s inner-west 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 under the age of 13 is incapable of understanding the illegality of their actions and therefore cannot be convicted of a crime.

The Victorian Children and Young People’s Commissioner launched an investigation into the case because WD had been in out-of-home care for years.

In committee annual reporttabled in state parliament on Thursday, Senior Commissioner Liana Buchanan said the case revealed some of the most “profound failures of the service system” she had seen.

“At each stage of WD’s childhood, opportunities were missed to disrupt the increasing risk to which WD was exposed and which she posed to herself and others,” the report said.

“Put simply, the systems – including out-of-home care, mental health, disability support, the police and justice systems – failed to meet her needs.”

WD spent three years being moved through 10 different “emergency care” placements, designed to act as emergency accommodation, at a cost of $3 million.

The commission said the placements were inadequate and unsafe and led to disruption of the girl’s schooling and access to support.

She was reported missing hundreds of times, sometimes for several days, before her arrest.

Efforts to respond to her absences were ineffective and “at times appeared to be affected by service fatigue, desensitization and a lack of clear and coordinated 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 nothing was effective, efforts were very fragmented and there needed to be significant escalation to bring all agencies together.

“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 put the “invisible” problem in the spotlight.

“I can’t change what happened in the past for this child,” she said.

“My interest was really in trying to make sure, given the pretty devastating failures of this child’s experiences, that we as a collective use these findings to really drive some urgent action.”

She made 19 recommendations, including improving department oversight and trust in emergency placements.

Other suggestions were coordinated, interagency responses to child sexual exploitation, less reliance on children to make formal statements to trigger a response, and greater access to forensic examinations for children with complex trauma and disabilities.

Children’s Minister Lizzie Blandthorn declined to discuss the details of WD’s case but said emergency care placements were rare.

“Since we’ve been in government, we’ve reduced urgent care placements,” she told reporters in parliament.

“We have one right now.”

She acknowledged that the services could do better, but would not count on who, if anyone, would be held accountable for the systemic failures suffered by WD.

The commissioner has not received a formal response to the inquiry’s recommendations from the Allan government since he was handed the report two months ago.

Ms Buchanan said the department had “drastically reduced” its use of urgent care placements from the end of 2023, but was not aware this was in direct response to the WD case.

During 2023/24, the commission recorded 1,892 reports of alleged child abuse and misconduct by workers and volunteers, up 30% on 2022/23.

There were a further 43 children who died within 12 months of their last involvement with child protection, including eight Aboriginal children.

Lifeline 13 11 14

Child Helpline 1800 55 1800 (for people aged 5-25)

1800 RESPECT (1800 737 732)

National Sexual Abuse and Reparations Helpline 1800 211 028