Inquest into the death of Kunmanara Forbes

Contributing factors

• Petrol sniffing and substance abuse
• Sexual abuse and exploitation
• Itinerant lifestyle with lack of consistent family care and supervision
• History of suicidal ideation and prior suicide attempt
• Multiple sexually transmitted infections (chlamydia, gonorrhoea, syphilis) indicating sexual abuse
• Failure to consolidate medical and protective information across agencies
• Inadequate inter-agency communication between FACS and health services
• Absence of mental health assessment and intervention following suicide attempt
• Inadequate review of medical records during child protection assessment
• No case conference to coordinate care
• Absence of adolescent health services in Northern Territory
• Staff shortages and resource constraints in FACS and health services
• Governance issues in remote community

Coroner's recommendations

1. Police Commissioner should ensure the Coronial Investigation Unit in Alice Springs is appropriately staffed and resourced to exercise investigative, oversight and liaison functions in relation to deaths reported to the Coroner in the Southern Command in a similar way to the Coronial Investigation Unit in Darwin
2. Police Commissioner should put specific strategies in place to ensure reportable deaths are investigated in a timely way, with the expectation that coronial investigation files of satisfactory quality will be submitted to the Coroner within 6 months from date of death
3. Director General for the Department of Health should introduce an Adolescent Health Service within NT Department of Health