Coroner calls for swift action to save ‘current generation’ in findings on suicide of child J in state care

The WA coroner has released his findings in the case of a young Kimberley boy who took his own life while in state care, saying his death came at the end of a life of “deep sadness”.

An inquest into the death of the 15-year-old, known only as Child J, was heard in Broome last year, four years after he took his own life following a split with his first girlfriend friend.

The inquest heard that the boy had a long history of trauma due to his father’s imprisonment and his mother’s escape from an abusive relationship, and that his fractured relationship with care placements and providers mental health had contributed to his turbulent life ending in 2017.

Throughout the inquest, Coroner Sarah Linton heard about the Aboriginal boy’s relationship with the Department of Communities.

Child J had 34 separate lifestyles by the time he turned 15 and had to deal with a revolving door of 30 social workers in 13 years.

There were also two failed attempts to reunite with his parents, one which ended when the boy’s father failed to collect him after a Christmas holiday in Broome.

Ms Linton and mental health professionals concluded that child J’s trauma from the abandonment had likely worsened during the two failed attempts to reunite him with his parents.(ABC News: James Dunlevie)

‘Inconsistency’ in care mirrors boy’s life

Ms Linton pointed to missed opportunities that could have helped the boy cope with his breakup, including a case in 2014 when he fell off the department’s radar after choosing to opt out of mental health help.

Another missed opportunity was when he was lucky enough to be correctly diagnosed at Princess Margaret Hospital in Perth.

Ms Linton said a major barrier that existed for child J appeared to be that he lived in the Kimberleys.

It was identified during the investigation that the Kimberley continued to be an exceptionally difficult place to work for child protection workers, particularly those who were often just starting out after university.

“Employment pressures and staff shortages also contributed to high staff turnover, although there were many and varied reasons why staff did not always stay long term in the Kimberley office of the department,” Ms Linton wrote.

In the days leading up to her death, Child J was assigned a social worker who had just graduated from university and taken on her first role in the Kimberley.

She later left the department after being placed on stress leave.

Broome Courthouse
The inquest into Child J’s death was heard in Broome Court last year, with witnesses including his foster family, mental health professionals and representatives from the Department of Communities.(ABC Kimberley: Tom Forrest)

In her findings, Ms Linton pointed to the independent report of child and adolescent psychiatrist Nadine Caunt, who had been commissioned to independently review the case of Child J.

“Dr. Caunt noted that, given the very limited services and resources available in the area at the time, she felt that those involved in her care were doing the best they could,” the findings state.

“While there were a number of missed opportunities to assess him more closely and try to identify why he was struggling to manage his behaviors and emotions, there were still many of engagement with Child J by the department and health workers, marred primarily by the lack of continuity of his care.

Ms Linton said it was clear the lack of consistency in Child J’s care was mirrored in the lack of consistency in his life, and that he struggled to deal with feelings of abandonment due to a ongoing trauma with his family.

He spent his life seeking meaningful relationships, and when he met his girlfriend, Ms Linton said, it was likely he saw her as an important connection in his life.

And when they broke up, he was unable to process the separation and regulate the emotions of hopelessness and sadness.

His body was found along with a photo of his girlfriend.

Image of a young boy looking over the Fitzroy River, you can only see his silhouette.
Research indicates that better funded and more appropriate mental health support is needed across the Kimberley.(ABC Kimberly)

Coroner calls for quick action

Ms Linton noted that the boy’s case was not exceptional.

“The reasons Aboriginal youth choose to commit suicide are complex and multi-faceted, and they have been explored in other forums at a much deeper level than I am able to go in this investigation,” said she writes.

“The WA Government has indicated its commitment to implementing changes that will hopefully not only change the future of the younger generations of Aboriginal and Torres Strait Islander children in this state, but will also help those who are currently faced with the many challenges faced by Child J. .

“For this reason, the government must act quickly if we are to make any meaningful effort to try to save the current generation.”

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