Inquest into the death of SG

Contributing factors

• Failure to establish and maintain safety plan after suicide attempt
• Lack of inter-agency communication and information sharing between DCJ, Department of Education, and CAMHS
• Premature closure of child protection file based on unverified reassurances
• CAMHS closure after two missed appointments without escalation or direct outreach to young person
• Failure of principal and deputy principal to open/read mandatory report email regarding suicide attempt
• School failure to implement mandatory support team and follow-up protocols
• Insufficient understanding by child protection caseworkers of cumulative trauma and suicide risk
• Absence of systematic follow-up mechanisms in school and child protection systems
• Under-resourcing of child protection casework teams leading to closure of reports due to 'competing priorities'
• Limited information available to CAMHS about patient's trauma history and risk factors
• Lack of direct outreach to adolescent by mental health services
• CAMHS and school counsellor not informed that child protection file was closed
• Isolation from school support during COVID-19 remote learning period
• No education provided to father regarding elevated suicide re-attempt risk after first attempt

Coroner's recommendations

1. NSW Department of Education to implement policy ensuring school counsellors access prior child protection history when meeting with suicidal students to assess cumulative trauma and post-traumatic stress
2. NSW Department of Education to undertake comprehensive review and implement clear suicide and wellbeing policy requiring: mandatory safety planning for all students reporting suicide attempts as soon as possible after attempt; documentation and joint sign-off by principal and counsellor if safety plan not developed; mandatory checklist clarifying steps and roles for school staff responding to suicide attempts; provision of information and resources for immediate support to staff, parents and students; ensuring policies are enacted at local level; implementation of mandated automatic follow-up by school counsellors not dependent on individual memory or capacity; implementation of additional oversight system for mandatory reports and e-referrals to child protection to prevent human error from leaving child unsupported
3. NSW Department of Education to deliver education and training package to school staff including principals, deputy principals, teachers and school counsellors on wellbeing, suicide prevention policies at local and state level, and practical training on responding to suicide attempts and suicidal behaviours
4. Department of Communities and Justice, NSW Department of Education and Child and Adolescent Mental Health Service, Hunter New England Local Health District to develop joint agreement ensuring cooperation, coordination, communication and information sharing in appropriate and timely manner in accordance with Chapter 16A of Children and Young Persons (Care and Protection) Act 1998, including: records and information shared between agencies when report made regarding child; where agency relies on external agency involvement in decision-making, external agency must be notified if no further action taken; agencies must implement memorandum of understanding or policy mandating staff follow up with counterparts at other agencies to ensure appropriate action for young person occurs
5. NSW Department of Education and Child and Adolescent Mental Health Service, Hunter New England Local Health District to develop education package for parents and carers of children who have attempted suicide or expressed suicidal behaviour, providing guidance on dealing with suicide attempts, suicidal behaviour, initiating conversations with young people, and general suicide and wellbeing education for parents including information about possibility of further attempts and risk factors; package should be provided following report to school counsellor or referral to CAMHS
6. Department of Communities and Justice to give consideration to risk of suicide, including weight given to child's previous suicide attempts, within comprehensive Prioritisation, Triage and Allocation Policy Review to ensure better identification and prioritisation of children most at risk