The findings of the Royal Commission into Institutional Responses to Child Sexual Abuse, and the subsequent amendment of state legislation have reduced barriers to civil actions for compensation for harm done to children in state institutional care. Mediation will be a common forum for the resolution of these disputes. Survivors of sexual abuse in state care have specific vulnerabilities in these mediations. Without mediators having adequate training, skills and knowledge in dealing with complex trauma and sensitivities to power imbalance among the parties caused by cumulative disadvantage, outcomes may be compromised. This article explores the literature and research into the unique profile of this cohort of plaintiffs and the uniqueness of these mediations, and concludes that they have special needs. Questions of justice and fairness are raised, together with ethical, regulatory and future research considerations.