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I spent 18 months travelling Victoria to find out why so many Indigenous kids are in out-of-home care. How long before we start bringing them home?

Three years ago, when I became the first dedicated commissioner for Aboriginal children and young people in Victoria, there were 922 Koori children living in out-of-home care in the state. We knew that was far too many, and greatly exceeding national rates. But we thought it was surely a small enough number that we could learn about each and every one of them personally, to find out what had happened, why their numbers were growing and why their experiences and trajectories were so poor. Just as importantly, we wanted to find out why so few of them were in the care of their own Koori kin, or connected to their community, culture and country. In 2014, in partnership with the department of health and human services, we launched Taskforce 1000: an 18-month journey across the state to critically review each child’s circumstances.

The aim was to bring together everyone responsible for providing services – child protection, paediatricians, mental health and sexual assault specialists, Aboriginal community-controlled organisations and community service organisations – who could help shine a light on that young person’s experience in the system designed to protect them. To go beyond the files, to understand why decisions had been made, or not made, and to offer solutions for each child.

Our findings, tabled this week in the Victorian parliament, should sound an alarm around the nation. Firstly, about why our kids go into care in the first place – overwhelmingly due to family violence and parental drug and alcohol abuse – and secondly, about what happens next.

Many children, of course, receive strong support and do well, but we heard case after case of highly vulnerable, deeply distressed children being failed at the hands of the state across multiple agencies, including child protection, out-of-home care, police, education and youth justice.

As well as often neglecting to address their physical, mental and emotional needs, our system is failing to address their familial and cultural rights, failing the families and communities to which they belong. Failing to learn the lessons of the stolen generations.

Against all policies, principles and guidelines, we saw many children who did not even know they were Aboriginal left for years in care – isolated from their family, culture and country – when they might have been in the loving care of Koori relatives.

More than 86% were case-managed by a non-Aboriginal agency, 91% placed with non-Aboriginal carers, and more than 40% separated from their brothers and sisters. In one case, four siblings, two per set, were case-managed in the same department office by two different practitioners who had no idea they were related and had completely different views on the mother’s capacity to provide care for them.

Thankfully, as a result of the Taskforce’s intervention, all four are now on a reunification plan to live with their mum.

In many other cases, siblings were separated because a grandmother’s house was regarded as too small for all of them. The same department responsible for child protection also manages housing, but in the cases I heard no one even bothered to follow up to see if something bigger could be found so the family could be kept together.

These are lessons for beyond Victoria too, as we await the investigation of the royal commission into juvenile justice abuses in the Northern Territory, knowing that for many the direct pathway from out-of-home care is the criminal justice system.

It’s impossible to say which of the Taskforce 1000 cases is the most distressing.

Lucas, who after years of abuse from his father was diagnosed at nine with post-traumatic stress disorder and would lie unsettled at night, crying, scared, describing shadowy figures hovering over his bed, and suffering from recurrent nightmares about his mother dying. Yet by the age of 12 – so young and deeply wounded and troubled – he had been held in isolation on numerous occasions in police and youth justice detention, restrained, handcuffed and subjected to routine strip searches.

Or Bert, who was five years old when he and his younger siblings first came to the attention of child protection. It took eight years and multiple episodes of harm before he was taken into care, where he disclosed experiences of sexual abuse to police. Two years later, when we reviewed his case, no charges had been laid and he had received no counselling.

These are children who were taken into care to keep them safe and well. Yet many are not safe and well in state care, and they have been denied safer and more nurturing options with Aboriginal family and community.

We were told time and again by child protection that they had been unable to trace a child’s Aboriginal family when we were able to track them down on Facebook within minutes.

Often no one even checked if a child was Aboriginal. This is not about paperwork or data collection; ascertaining a child’s Aboriginal status is supposed to trigger a range of interventions and protections. I say “supposed to” because my office also looked at one of the most fundamental protections, the Aboriginal Child Placement Principle, which upholds the right of Aboriginal children to be placed where they are safe in their culture and identity. A review of 65 random files selected by child protection did not uncover a single case where agencies complied fully with this principle. Not one. Nor any effort from the top to even check that this process was occurring.

This demonstrates non-compliance and deficiencies across many parts of the system, the impact of ignorance and indifference, lack of accountability, and of an embedded racism that does not value Aboriginal family and culture.

It also echoes the warning heard at the Northern Territory royal commission this month against an “inquiry mentality”, in which reporting is accepted as a replacement for results.

In each Taskforce 1000 case, we asked child protection case workers to put together genograms – powerful extended versions of family trees that can reveal relationships and experiences over generations – to tell the child’s story.

As we laid them out across desks or on the tables and floors for each Taskforce panel, these documents provided a graphic illustration of the impact of invasion and colonisation, past policies of assimilation, and of intergenerational disengagement and disempowerment.

Each relative was represented in a little box. There were so many boxes marked with a cross, indicating family members who had committed suicide. So many with symbols to indicate they had been in child protection themselves. We also saw generations of connection with the criminal justice system, unemployment, poverty, and poor education. We saw the overriding impact of the past on the present.

We didn’t need to look to the next pages. We know what future awaits so many of these children if we don’t intervene now and in the right way.

Victoria has strong policies, and a state government, premier and minister committed to self-determination and fundamental reform in family violence and child protection. But the system is just not working on the ground for Koori kids – and that is a fact.

For me, each and every story we heard through Taskforce 1000 was distressing. But what distressed me most was that, since we launched the inquiry, the number of Koori children in out-of-home care in Victoria has doubled. There are now nearly 1800. How high does it have to go before we start to bring them home?

• The Taskforce 1000 report is published by the Commission for Children and Young People.