Finding into death of Shyra Lee Bloomfield

Contributing factors

• inhalant intoxication immediately prior to death
• recent relationship breakdown
• chronic inhalant (chrome) addiction
• disengagement from education system
• situational crisis with poor emotional coping resources
• family violence and parental mental illness exposure
• learning difficulties and literacy challenges
• fragmented service delivery

Coroner's recommendations

1. DHS should ensure that practice standards support all young people known to Child Protection being engaged with educational services
2. DHS should ensure that high risk adolescent processes identify all young people whose case management requires additional quality assurance monitoring, not limited to those receiving specialist resourcing
3. DHS should examine whether Aboriginal high risk adolescents receive sufficient access to Intensive Case Management Services and consider need for specialist ICMS Aboriginal service response
4. DHS should undertake review of training materials to promote understanding of suicide risk in adolescents
5. Further investigation of effectiveness and appropriateness of restricting access to volatile substances used for chroming
6. Comprehensive and whole-of-community response to volatile substance abuse required
7. More flexible, individually-tailored educational options needed for young people with complex needs and high-risk behaviours
8. Enhanced training for DHS workers in drug, alcohol, and mental health issues
9. Closer coordination between education and child protection services including referral to MIRT for difficult cases
10. Cultural identity considerations embedded in service provision for vulnerable Aboriginal youth