There were a total of 267 reports between the children over their lives, an average of eight reports per child.Â
Some children faced far more reports than others, with three receiving more than 21 alerts and one infant, first reported at six days old, subject to 28 reports.
"The commission observed that many of these reports contained information of ongoing and/or escalating risk to the children and young people," the report said.
"Yet most reports were assessed as not being at significant risk nor requiring a statutory response and were closed."
Multiple risk factors were flagged for each child across their lifetime, with the most common being family violence, substance abuse and mental illness.
The deaths of the children were attributed to suicide, illness and accidental death caused through incidents such as drowning and house fires.
Seven-year-old Maddy, who had an intellectual disability and autism spectrum disorder, was the subject of seven child protection reports before her death in a car accident.
Six reports were closed at intake and one was investigated.
Victoria's specialist service for family violence and families, The Orange Door, identified several risks but determined they could be addressed by her school despite information she had been withdrawn from attending and her parents were uncontactable.
"This decision left Maddy and her family with no service provision, and the concerns for Maddy remained unaddressed," the report said.
A two-year-old Aboriginal girl, referred to as Nikki, was subject to six reports before her death.
There was evidence her older siblings were taking on a caregiver role but child protection ruled the reports did not meet the threshold for statutory intervention.
Chief among the report's 17 recommendations was for the Victorian government to increase the age limit for child protection intervention from under 17 to under 18.
The Department of Families, Fairness and Housing was also pushed to communicate a clear threshold for statutory intervention to ensure a shared understanding of risk.
Other recommendations centred on strengthening referrals, creating a point of contact for professionals to seek advice, and increasing funding for services and programs.
The department is considering all recommendations.
Children Minister Lizzie Blandthorn said the Victorian government had invested more than $4.8 billion into the child and family services system.
"Every child deserves to be safe where they live, learn and play," she said.
Opposition Leader Jess Wilson said the coalition would consider the report's recommendations.
"We're seeing a system that unfortunately continues to fail the most vulnerable children in our society," she told reporters.
"We need to do better."
1800 RESPECT (1800 737 732)
Lifeline 13 11 14
Men's Referral Service 1300 766 491
Lifeline 13 11 14
Kids Helpline 1800 55 1800 (for people aged 5 to 25)
11°C