Inquest into the death of Didbala Anzac

Contributing factors

• Casual carers unfamiliar with Didbala's complex history and safety plan
• Failure to recognise acute suicide risk when Didbala became psychotic and aggressive
• Failure to communicate mental health risks to attending police
• Police unaware of Protocol for Police Contact with Children in Intensive Therapeutic Residential Care
• Police lack training on vulnerable youth in out-of-home care
• Confusion about whether Didbala was blocking the bedroom door delayed forced entry
• Mistaken belief by Shift Sergeant that Didbala had verbally responded to police
• Keys to bedroom appeared not to work, causing further delay
• Territory Families case management neglect due to excessive caseloads and staff turnover
• Inadequate inter-agency coordination between Territory Families, NT Health, and CASPA
• Failure to progress NDIS application despite recognised eligibility
• Insufficient engagement with extended family
• Lack of scenario-based training for carers on emergency situations
• Consumption of cannabis and alcohol that evening

Coroner's recommendations

1. CASPA ensure workers inform first responders that risk of self-harm exists for all children in their care
2. CASPA provide one-page critical information summary for each child to first responders
3. CASPA implement scenario-based training on emergency/crisis scenarios including police attendance
4. CASPA ensure staff have time to regularly read and review critical documents about each child
5. NT Police, Territory Families and CASPA review and implement the Protocol for Police Contact with Children in Intensive Therapeutic Residential Care
6. NT Police maintain clear alerts in police systems identifying suicide and self-harm risks
7. NT Police ensure frontline officers receive training on vulnerable children in out-of-home and intensive therapeutic care
8. Territory Families review ITRC funding model to provide for award wage increases and complex needs funding
9. Territory Families ensure each child has a Case Manager with manageable caseload (noting CASPA caseload is 5)
10. Territory Families urgently address unfilled case management positions in Big Rivers Region and consider innovative models including NSW delegation to CASPA or Victorian ACCO model
11. Territory Families set benchmark timeframes for NDIS assessments and applications
12. Territory Families amend Essential Information Record to separate mental health from self-harm/suicide risks
13. Territory Families review death notification procedures to ensure cultural sensitivity and ensure families are contacted appropriately
14. Territory Families urgently establish High Risk Youth Panel and monitor effectiveness
15. NT Health implement Child and Adolescent Mental Health Remote Area Team in Big Rivers Region
16. NT Health set benchmark for eliminating seclusion and restraints in child mental health facilities