Coronial
NTcommunity

Inquest into the death of Kailab

Deceased

Kailab Wolfgang Moir

Demographics

15y, male

Date of death

2022-07-03

Finding date

2025-04-04

Cause of death

multiple injuries caused by a motor vehicle accident

AI-generated summary

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 different placements. Critical failures included: delayed FASD diagnosis (not confirmed until February 2021 despite indicators since 2018 and 2012); gaps in paediatric follow-up between 2016-2018; inadequate reunification planning with his mother (three failed attempts); closure of placements while he was in detention without prior alternative identified; and failure to share his FASD diagnosis with police. While Territory Families and CASPA provided some appropriate services, systemic issues around placement instability, late disability diagnosis, poor information management, and gaps in information sharing with police contributed to deteriorating outcomes and his entry into youth justice. Earlier diagnosis and consistent medical oversight could have better supported behavioural management and reduced trajectory to offending.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricspsychiatrypsychologyneurology

Error types

diagnosticsystemdelaycommunication

Drugs involved

alcoholmethylphenidatemethylphenidate

Clinical conditions

foetal alcohol spectrum disorder (fasd)ADHDattachment disordercomplex traumasubstance misuse

Contributing factors

  • stolen vehicle involved in criminal offences
  • dangerous driving by vehicle operator
  • placement instability and multiple changes in out-of-home care
  • late diagnosis of FASD despite early indicators
  • gaps in medical follow-up for behavioural concerns 2016-2018
  • failed family reunification attempts
  • closure of placements while child in detention without alternative identified
  • inadequate information sharing with police regarding FASD diagnosis
  • poor coordination of multiple service providers
  • absconding from care placements and breaching bail conditions

Coroner's recommendations

  1. NT Government through Department of Attorney General and Justice ensure adequate funding for legal representation of families at Coronial Inquests
  2. CASPA identify a 'key worker' for each child in their care as provided for in the ITRC contract
  3. NT Department of Children and Families (formerly Territory Families) approach placement closure as a matter of last resort, taking into account importance of stability and continuity of care
  4. Placements should remain open when a child goes into detention or short-term intervention program where possible and appropriate to avoid criminalisation of care; if closure necessary, alternative placement must be identified first
  5. NT Department of Children and Families streamline therapeutic interventions and services to avoid unnecessary duplication and overservicing
  6. NT Department of Children and Families review currently funded ITRC model to explore more suitable intensive care options for high-risk young people with extreme and complex needs or significant disabilities
  7. NT Department of Children and Families review whether recommendation 15.1 (FASD screening) of Royal Commission into Protection and Detention of Children has been implemented and ensure Territory Families has access to this information
  8. NT Department of Children and Families share information regarding FASD with police
  9. NT Department of Children and Families broadly review information sharing procedures with NT Police including missing persons reports to ensure sharing of information regarding disabilities of young persons
  10. NT Police include alerts in their system (SERPRO) as to any known disabilities to ensure safe and appropriate responses to, care and management of young people interacting with police
Full text
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