A coronial inquest into the suicide deaths of 12 young Aboriginal people in the Kimberley has found the Department of Child Protection and Family Support failed to act on allegations of violence, neglect and drug abuse in four of the horrific cases.
It has also been revealed for one of the four cases, a Youth Justice team delayed arranging a mental health referral for a 12-year-old girl in Wyndham, despite the young girl’s family twice telling police she wanted to kill herself.
The young girl took her own life on the same day her appointment to see a visiting mental health professional was cancelled by the service for the second time. She never accessed any assistance.
The department was also found to have failed to support the girl in the last 11 months of her life, despite knowing she was living in an overcrowded and dysfunctional household, using alcohol and drugs, and walking the streets at night unsupervised.
The adverse findings against the government departments have formed part of State Coroner Ros Fogliani’s 42 recommendations handed down on Thursday, following the completion of the inquest.
10-year-old girl from Looma
Of the four cases where adverse findings were made against the Department of Child Protection and Family Support, one related to the 10-year-old girl who took her own life in Looma Aboriginal Community in 2016, sparking the coronial inquest into her death, and others like hers.
Two-and-a-half years before her death, shortly after her sister had committed suicide, a social worker expressed concerns to the department that the girl, whose mother was not fit to care for her, had been hit by a carer.
The social worker informed the department of the girl's sister’s recent suicide, and the violence the girl had witnessed between her parents in the past.
Nothing was done.
Four months later the same social worker reported to the department the then-eight-year-old girl was no longing attending school, had stopped engaging with her, and had moved from Perth to the remote community of Looma.
No action was taken and the department advised the social worker the girl’s case had been closed a month prior as there were no child protection concerns that had been noted.
Two years later, the girl took her own life.
The department, during the coronial inquest, conceded the girl’s welfare should have been checked following the allegations of violence and her sister’s suicide; and her living arrangements should have been reviewed, following her move to Looma
Counsel assisting the Coroner, Phillip Urquart submitted the girl’s family life, which included entrenched violence, alcohol abuse and neglectful parenting, coupled with her sister’s suicide, ought to have “cried out” for the girl to be assessed.
“It cannot in retrospect be known what the outcome of those assessments would have been, but I am satisfied that they could potentially have helped this child,” Ms Fogliani found.
The department has since changed its policy so that if a concern is raised about one child in a household, the other children within that household are also assessed.
12-year-old girl from Wyndham
Authorities were made aware in 2009 that a 12-year-old girl from Oombulgurri Community was living in a dysfunctional household from at least the age of eight.
The closure of the community in 2010 forced the distraught family to move to Wyndham, where their residence became known as a party house and was often overcrowded with people abusing alcohol.
The girl rarely attended school, smoked ‘gunga’ and drank alcohol, and often walked the streets at night unsupervised.
One month before her death in February 2013, her family told police on two occasions she wanted to hang herself.
Her tragic death came on the day she was meant to see a visiting mental health professional, however the meeting was cancelled due to service priorities in other areas of the Kimberley.
It was the second time in days the meeting had been cancelled following a three week delay by the Youth Justice team to refer her to the Child and Adolescent Mental Health Service for assessment after the agency learnt of her suicidal thoughts.
She never accessed any mental health assistance.
The delay in assisting the girl was due to staff shortages, and the difficulties around recruiting people to the East Kimberley.
The Youth Justice team now has an additional regional manager (two in total) and three additional officers (11 in total) to better manage the area’s case load of around 100 children.
The inquest also found the girl was not adequately assessed by the Department of Child Protection and Family Support in the last 11 months of her life, despite authorities knowing she was living in unsafe conditions.
Ms Fogliani said various agencies had tried, however, to assist the girl’s family over the years.
“It cannot now be known what the outcome of that (mental health) referral might have been,” she said.
“Suicide is very difficult, if not impossible, to predict.
“With the benefit of hindsight the matter was clearly urgent. The child was very vulnerable as a result of long-standing and entrenched trauma and she had already expressed an intention to take her life.
“Numerous attempts had been made by agencies over an extended period to help her and her family under very difficult and trying circumstances.”
13-year-old girl from Kalumburu
On two occasions, the Department of Child Protection and Family Support was tipped off that a young girl in the Kimberley, aged around five or six, was being neglected by her mother and was asked to intervene.
When the department learnt the child had been voluntarily placed in the informal care of extended relatives, no assessment of the child, or her living conditions was conducted and she was never placed under the agency’s care.
The department did not know where she lived from the time of the most recent complaint in 2006 to her death in 2013.
It was revealed during the inquest she was moved to Derby to live with extended family where she witnessed alcohol abuse and domestic violence. She then lived with her aunt in Kalumburu for six or seven years until 2011 when her mother took her back to Derby.
During the inquest, the department conceded that at the time, it was common for the agency to rely on informal arrangements when a child went to live with other family.
It now requires more formal placement arrangements which include an assessment of the child’s living conditions and checks-ups.
The Department of Child Protection and Family Support previous Executive Director of Country Services and Therapeutic Care, Ms Julianne Davis, told the inquest no assessment of the child was ever undertaken.
“A retrospective review of [the child’s] case highlights the prominence of alcohol abuse, domestic violence, neglectful parenting, the absence of a responsible legal guardian and the presence of cumulative harm,” she said.
“It is also evident that on a number of occasions no assessment was undertaken in relation to [her] safety and wellbeing and care arrangements.”
17-year-old boy from Broome
In 1997, Department of Child Protection and Family Support officers were notified of a boy who had been born into a dysfunctional family.
In 1998 and 1999, the agency failed to adequately assess the boy’s risk, and in 2011, it ignored a plea from a carer for him to be “rescued” from his living arrangements, which were described as chaotic and transient.
The latter request was never investigated, with the department admitting during the inquest that the boy should have been assessed.
He died in April 2015.
The coroner found that given the multiple problems experienced in the Kimberley, there was no justification for finding that the act or omission of a particular person, officer or agency caused or contributed to any of the suicides.
She also made no adverse comment about the family members of the children and young people, who she said themselves had endured significant trauma and disadvantage.
She accepted simply providing more funding would not solve the issues facing families in the Kimberley, and instead called for a major policy reform which empowered Aboriginal people to have a say on policies which impacted them.