Deceased
Master W, Miss B, Master JK
Date of death
2018-2019
Finding date
2020-12-15
Cause of death
volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodorant aerosol)
AI-generated summary
This inquest examines three children (Master W aged 12, Miss B aged 17, Master JK aged 13) who died from volatile substance abuse in remote Aboriginal communities in the NT between 2018-2019. All three were known to government agencies including VSA assessors, child protection, health, education and police. Despite clear evidence of severe risk, they were not properly assessed under the Volatile Substance Abuse Prevention Act 2005. Critical failings included: failure to conduct timely assessments within required 2-week timeframe; absence of proper care plans and treatment recommendations despite being at severe risk; lack of aftercare planning after rehabilitation discharge; failure to escalate to the Chief Health Officer; gaps in inter-agency communication; and inadequate school engagement. The coroner found the Top End Health Service continued unlawful practices despite earlier 2017 findings in the Laurie inquest making identical recommendations about legal compliance. The use of monitoring without formal assessment, expecting 2-month periods without reports before closing files, and failure to implement treatment orders when voluntary rehabilitation was refused were all contrary to law and guidelines. Systemic failures by Territory Families included inappropriate screening-out of child protection notifications. The coroner emphasised the need for law compliance, regional rehabilitation services, and locally-based community workers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …
Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.