Deceased
Sammy
Demographics
9y, female
Date of death
2020-03-14
Finding date
2021-11-25
Cause of death
suicide by hanging
AI-generated summary
A 9-year-old Aboriginal girl died by suicide while in out-of-home care. She had been removed from her Aboriginal parents at 10 months of age and placed with non-Aboriginal carers despite legislation requiring Aboriginal children be placed with family or Aboriginal carers where practicable. The coroner found the Aboriginal Placement Principle was not followed: family members offered to care for her, but assessments were delayed or stalled for years on bureaucratic grounds. She had experienced significant trauma including parental separation, multiple placement changes, father's hospitalisation, and brother's removal. Play therapy was approved but never provided. She had delayed speech, possible FASD (unassessed), and was possibly over-medicated with methylphenidate. The coroner found she was in a high-risk cohort (out-of-home care plus ADHD) but did not receive trauma screening or counselling despite recognition of her need. Her death was likely preventable through appropriate cultural placement, trauma assessment and therapy, and early intervention.
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
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