How Child Protection Systems Miss Medical Neglect: Lessons From the Elizabeth Struhs Inquest
Elizabeth Struhs was eight years old when she died on 7 January 2022. The cause was diabetic ketoacidosis. Without insulin, the body cannot move sugar from the blood into cells; it burns fat instead, and acids build up until they poison the blood and attack organs. Her father had stopped giving her insulin days earlier. The family belonged to a small religious sect known as the Saints, which rejected modern medicine and trusted in divine healing.
The file was open. The risk was not seen.
Elizabeth had already come to the attention of multiple government departments after a 2019 hospitalisation for diabetic ketoacidosis. Her parents were convicted of child neglect after delaying medical help. The Canberra Times reported that a child safety officer later admitted being “out of their depth” on the family’s extreme beliefs. That officer approved then six-year-old Elizabeth’s return home, confident her father would “give it a go” with her diabetes treatment. Child Safety was willing to accept “some risk,” a senior guidance officer testified.
The inquest also heard about procedural strain. Specialist officers carried an “incredible workload.” There was no formal training for incoming staff and no specific process to track cases or aid handover. Kerrie Struhs had told a teacher, “I believe we have a God that heals,” when asked about Elizabeth’s insulin. The warning was not hidden. The Guardian reported that Kerrie had repeatedly told police, healthcare workers, teachers, parole officers and child safety workers about her views, and that she would do the same thing again.
Curiosity as a child protection tool
The coroner’s central observation was not that workers lacked information. It was that they lacked curiosity about what the information meant. “What’s striking in the evidence that’s available to me, is an acceptance of this mother’s beliefs without any curiosity about why she held them,” the coroner said, according to The Guardian. The church group was ultimately deemed a source of support by child safety.
That judgment sits at the heart of the case. A belief system can comfort a family and still become a closed loop that normalises danger. Child protection workers are trained to assess immediate safety, parental cooperation and support networks. When a parent is calm, certain and backed by a church, the same signals can read as stability. The inquest heard that none of the institutions seemed to ask the harder question: what happens to this child if the family’s faith and her medical needs never align?
Where law and belief collide
All 14 adult members of the Saints were convicted of Elizabeth’s manslaughter, The Guardian reported. The case has also produced a policy question. Victoria’s inquiry recommended creating a new offence akin to the domestic violence offence of coercive control, one that could apply to an organised group such as a cult. That is a recommendation, not an established charge in this case.
The practical lessons are less dramatic. Ask what a family believes and how those beliefs shape care. Treat a sect as a risk factor to assess, not automatically as a support. Give child protection staff training and case-tracking tools. The cost of missing those steps is measured in a child’s life.