The homeless boy was among 70 child deaths probed in a report that indicated children were being lost in Queensland's residential care system that had "forgotten how to care".
The boy had entered residential care in early adolescence after his sole parent's death and been exposed to issues including domestic violence and abuse, Queensland's Child Death Review Board annual report said.
He spent hours unsupervised each day after being moved to a short-term placement, often returning in the early hours of the morning affected by substances.
Before his death, the boy had four different primary placements, spent 12 nights in a watchhouse and another nine in youth detention.Â
"He was homeless, had no safe place to sleep, was living out of a cardboard box, had no place to shower, no clean clothes and no food to eat," the report said of his death.
The boy was among a string of examples highlighted in the report by the board that reviews kids who were known to the child protection system in the 12 months prior to their deaths.
It revealed that for too many of the young people reviewed in the 2023-24 annual report, residential care was unable to meet their needs for connection, love, safety and stability.
The report made nine recommendations with a strong focus on the system's role as a parent and how it responded to children and families in need.
"I've certainly met many great workers in good houses who are doing their best," Child Death Review Board board chair Luke Twyford told AAP.
"What I am very clear on is that the design of the system is wrong."
Mr Twyford called for more prevention services to be set up by state government to identify what was causing kids to enter the child protection system.
Numbers are rising with 951 kids in residential care by June 2019 and 1582 by 2022.
As of June 2023, the report said there were 1763 children placed in Queensland residential care.
"We are paying people to create documents and plans and safety assessments, but no one is clearly performing a loving and caring parental role, and that has to change," Mr Twyford said.
"What we're seeing is people performing transactional roles, children moving from place to place and being lost into a system that has forgotten how to care."
Of the 70 deaths reviewed, 41 per cent were due to natural causes, 11 per cent transport-related and nine per cent due to suicide.
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