Coronial
QLDother

(P) a thirteen year old girl

Deceased

P

Demographics

13y, female

Coroner

Ryan

Date of death

2012-04-11

Finding date

2015-10-09

Cause of death

Multiple injuries due to motor vehicle accident

AI-generated summary

A 13-year-old Aboriginal girl in residential care absconded with a vehicle after an extended violent altercation with youth workers and died in a high-speed motor vehicle crash. She had extensive trauma history, PTSD, reactive attachment disorder and ADHD. The coroner found the youth workers acted appropriately and no police pursuit occurred. Key systemic issues included insufficient therapeutic residential care options, fragmented mental health services, lack of permanency planning, and inadequate assessment of cumulative harm. The Department made appropriate use of available services. Critical deficiencies were identified regarding therapeutic capacity, trauma-informed care, training standards for carers, and early intervention services—issues comprehensively addressed in the Carmody Report recommendations.

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

Specialties

paediatricspsychiatryforensic medicine

Error types

systemdelay

Clinical conditions

post-traumatic stress disorderreactive attachment disorderADHDintergenerational traumadomestic violence exposurechild abuse and neglect

Contributing factors

  • Absconding from residential care facility with vehicle
  • High-speed driving with inexperience
  • Inability to negotiate road bend at high speed
  • Complex trauma history with PTSD and reactive attachment disorder
  • Inadequate therapeutic residential care capacity
  • Fragmented mental health services
  • Lack of vehicle immobilisation measures
  • Placement instability and lack of permanency planning

Coroner's recommendations

  1. Department of Communities Child Safety and Disability Services work with licensed care services to implement policies and procedures, including tracking devices and PIN immobilisers, to prevent children with complex needs from accessing vehicles
  2. Review the extent to which licensed care services should engage QPS to respond to placement-related behaviours in implementing Recommendation 8.7 of the Carmody Report, and consider an audit tool to monitor police involvement and outcomes for young people in care
  3. Department of Communities Child Safety and Disability Services review its Positive Behaviour Support policy to provide clearer guidance on circumstances for reactive restraint and types permitted, with emphasis on risks including asphyxiation
Full text
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