Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Contributing factors

• sexual abuse and assault from age 12-13 years
• domestic violence and threats
• lack of coordinated child protection response despite multiple notifications
• perfunctory police investigations
• failure to escalate to senior staff or implement safety plans
• failure to monitor school attendance despite statutory obligations
• failure to provide trauma-informed assessment and support
• failure to identify and report suspected sexual assault and domestic violence
• inadequate mandatory reporting
• lack of mental health and counselling follow-up after crisis presentations
• absence of coordination between agencies despite safety coordination groups
• community services controlled from Darwin without local community control
• resource constraints and staff shortages affecting child protection response
• cultural insensitivity and lack of trauma-specific training
• unprotected access to alcohol and intoxicated state at time of death (Layla)
• inappropriate provision of contraception without comprehensive assessment of sexual abuse risk
• removal of crime scenes by family members resulting in loss of forensic evidence
• delayed police investigations and contaminated crime scenes
• reluctance of community members to provide information to police

Coroner's recommendations

1. Multi-Agency Community and Child Safety Framework be legislated to ensure mandatory cooperation, coordination and information sharing in a timely manner
2. Department of Education ensure appropriate and continued engagement with all children and their families who are of compulsory attendance age in remote communities
3. Training of primary health care staff and paediatricians in recognising abuse and mandatory reporting obligations
4. Strengthening consultation process between primary health care teams and the Sexual Assault Referral Centre
5. Finalisation of Social Emotional Wellbeing Program including training for staff, referral pathways, complex case conferences and recognition of distress due to abusive relationships
6. Finalisation and implementation of audit tool to monitor prescription of Implanon in girls under 16 years to ensure guidelines requiring comprehensive assessment and mandatory reporting are followed
7. Better case management discussion between agencies within Multi-Community and Child Safety Teams Framework
8. Implementation of Safeguarding model with legislation making explicit that everyone working with children has duty of care to keep them safe
9. Framework must have sufficient flexibility to allow communities measure of control over services rather than just participation
10. Framework must have system to evaluate and review its effectiveness
11. Police to continue education program addressing investigative and unconscious bias
12. Police to implement strategies to develop relationships with communities including recruiting more Aboriginal Community Police Officers and expanding remote station staffing
13. Police to implement recommendations from Forensic Services review
14. Education Department to improve school attendance monitoring and responding to poor attendance, improve data collection, engagement of remote students, support for remote Aboriginal students attending boarding schools, and development of tools to identify vulnerable children
15. Territory Families to implement Signs of Safety Model for more holistic assessment, recruit more Aboriginal and Torres Strait Islander staff in remote areas, and continue programs to improve capacity to recognise cumulative trauma and sexual harm
16. Recognition that communities must have real control over services and that externally-imposed models without local control are ineffective
17. Urgent action required immediately rather than future promises