When early last year the ACT's highest court found five children had been wrongly removed from their mother in 2013 it caused outrage and sparked the current Legislative Assembly inquiry.
Over the past two weeks, the inquiry committee has heard damning evidence, from people including the ACT Human Rights Commissioner, about the systemic problems with the child protection system in Canberra.
The evidence has painted the picture of a system plagued by a lack of transparency, one with a combination of legal and bureaucratic barriers, and a culture of secrecy which blocks foster carers, family members and advocates from accessing critical information.
The majority of witnesses have expressed concern that so few decisions made by the child protection agency, including those regarding the child's living arrangements, are subject to external review under territory law.
The problem is, many of these issues have been raised before.
The need for external review was raised in official findings as far back as 2003, and yet only after the details of the case of the five children emerged in the media last year did the government act and release a discussion paper on the topic.
In 2003, the Standing Committee on Community Services and Social Equity found one of the chief issues was the lack of external review of decisions. Even back then, it recommended a model be established to enable that.
The following year, Cheryl Vardon reported that external oversight is vital to a well-performing system.
The 2014 Vardon report was commissioned in response to complaints that the government had repeatedly failed to uphold its own standards in relation to referring allegations of abuse in care to what was then known as the Office of the Community Advocate.
The report found a "the majority [of foster carers] expressed the view that decisions often appeared to be subjective, were inconsistent, and were not well documented or communicated". It went on to say that submissions highlighted a "lack of independent grievance structure".
It said parents, carers and agencies all relayed stories of frustration about having nowhere to go when they disagreed with Family Services about placement decisions, care plans and contingency payments. It made a specific recommendation for merits review by tribunal, overseen by the Children and Young People Commissioner.
Then in 2016, following the horrific murder of nine-year-old Bradyn Dillon at the hands of his father, the Glanfield report said a similar thing.
It looked at review mechanisms and found it was not possible to review many decisions in the ACT except, in some circumstances, through the courts.
In 2017, Liberal MLA Elizabeth Kikkert moved a motion calling on the government to commission a review into the lack of oversight measures, which are designed to keep a system accountable for its actions.
When the current inquiry was launched in May last year, Liberal MLA Nicole Lawder stated her party had raised these issues time and time again.
"We have heard from inquiry after inquiry. We have seen report after report. We have seen in recommendation after recommendation after recommendation the need for better information sharing and better review of decisions," Ms Lawder said.
External review is, once again, a resounding issue in the current inquiry's public hearings.
The extent to which territory law shields decisions made by the ACT's child protection agency from external scrutiny has been raised again - the very same issue that was raised in 2017, 2016, 2004 and 2003 and probably many times in between.
Even the ACT Minister for Children, Youth and Families Rachel Stephen-Smith told the hearing on Wednesday that "everyone agrees, including me" that more external review options should exist for child protection decisions.
ACT Human Rights commissioner Helen Watchirs told Tuesday's hearing that the lack of external review options was among the reasons why the territory's child protection act "falls well short" of human rights standards.
These decisions being made are the types of decisions that can affect a child for the rest of their life: where they live, who can visit them and the frequency of those visits.
In the case of the mother whose children were wrongly removed, the children were ultimately only allowed to see their mother for eight hours a year.
It was sheer luck that a senior barrister took on her case and pursued it in the ACT's highest court that she was able to successfully challenge that initial decision to remove the children from her.
Advocates have expressed concern that these types of cases might not be one-offs, but just the ones that have brought the problems to the forefront.
Ms Stephen-Smith rightly said the government needs to ensure the changes made to the system are the right ones. But not implementing key recommendations from previous inquiries continues to put children at risk, and the outcomes are unacceptable.
Given it was raised 16 years ago, the message that these things take time to change is getting tired.
The Royal Commission into Institutional Abuse taught important lessons about what happens when a system dealing with children isn't transparent and people aren't held to account.
Of course, it should go without saying that the identities of these children be kept from prying eyes. Everyone agrees that the main goal is to protect them and keep them safe.
But without proper oversight or accessible external review mechanisms, the government is ultimately causing harm to the very people they're tasked to protect.
We've been here before. A child has died. Children are being wrongly removed from their families.
We now know the threshold for the government to hold an inquiry, but what's the threshold for them to act on it?