Pini, Bailey Ezekiel

Contributing factors

• Forcible entry to locked office by youth residents
• Car keys stored in accessible correspondence tray rather than secure safe
• Excessive speed by inexperienced 13-year-old driver
• Wet road surface
• Worn vehicle tyres below safe limits
• Driver inexperience and lack of licensing
• Insufficient overnight staffing (single 63-year-old carer for four adolescents)
• Inadequate security measures against foreseeable breach attempts
• Grief and homesickness of recently bereaved adolescent

Coroner's recommendations

1. Install an appropriate dedicated key safe at the Sarina Youth residential facility; the safe should be capable of being affixed to floor or wall and equipped with a combination lock, designed to resist attempted forced entry by residents using foreseeable methods
2. Endorse (but not formally mandate state-wide) that the Department fund providers for 'awake rostered staff members' on an as-needs basis when cohort dynamics and behavioural risk factors indicate escalation
3. Review and clarify IFYS and Department policy on car key storage to explicitly extend to both official vehicles and carers' personal vehicles, not only IFYS vehicles
4. Implement an alarm system in addition to secure key storage as an additional layer of protection in office areas
5. Proactively arrange and communicate to residents planned visits to family, particularly around significant dates such as anniversaries of loss
6. Conduct a state-wide review to determine whether key-safe installation, staffing level adjustments, and funding model changes should apply beyond the Sarina facility to other residential facilities with similar risk profiles
7. Seek advice from Queensland Police Service Crime Prevention Units or professional locksmiths on appropriate safe specifications
8. Consider re-visiting funding arrangements between the Department and care providers, particularly where cohort behavioural issues escalate beyond single-carer management capacity