Finding into death of Zakiya Crystal Lisa Thomas
Deceased
Zakiya Crystal Lisa Thomas
Demographics
15y, female
Date of death
2015-05-17
Finding date
2016
Cause of death
Hanging
AI-generated summary
Zakiya, a 15-year-old Barkindji Maraura woman, died by hanging at Mildura Base Hospital following a family argument about repaying a borrowed $300. She had disclosed experiences of childhood sexual abuse by her uncle, physical and emotional abuse by her step-father, family violence, and suicidal ideation to multiple agencies. Significant failures occurred: Child Protection closed her case after telephone assessment without face-to-face follow-up or corroboration from CAMHS who held critical safety information; CAMHS did not share her disclosed family violence, drug/alcohol abuse, and explicit suicidal planning with other agencies; and Aboriginal-specific culturally competent assessment and intervention was lacking. Multiple missed opportunities for escalation and inter-agency collaboration were identified, particularly given her Aboriginal status, documented suicide risk with stated means, and known family violence exposure. Recommendations emphasize improved family violence risk assessment, inter-agency protocols, cultural competency training, and dedicated resources for Aboriginal youth mental health services in the Mildura region where suicide rates among Aboriginal youth were elevated.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- childhood sexual abuse by uncle
- physical and emotional abuse by step-father
- family violence exposure
- suicidal ideation with explicit planning
- depression and low mood
- sleep disturbances
- family conflict and overcrowding
- intergenerational trauma
- failure of Child Protection to conduct adequate assessment
- failure of CAMHS to share critical safety information
- lack of inter-agency communication and coordination
- lack of culturally competent Aboriginal services engagement
- acute precipitant: argument with mother about repaying borrowed money
Coroner's recommendations
- Child Protection and ACSASS should review systems for joint input and engagement with vulnerable Aboriginal youth; establish protocol ensuring investigations involving Aboriginal youth are not completed without input from both services
- Victorian Government, Child Protection and MDAS should consider high rate of Aboriginal youth suicides in Mildura region in future planning and resource allocation
- CAMHS should review policies and training on family violence risk assessments, information sharing with relevant agencies, and family violence safety planning for patients disclosing family violence
- Mildura Base Hospital should review policies and training for all clinicians to refer Aboriginal or Torres Strait Islander patients to internal Aboriginal Health Unit for cultural support; incorporate cultural training for hospital staff
- MDAS should consider: (a) partnership with Youth Affairs Council Victoria and Koorie Youth Council to develop Aboriginal youth mentoring program (Marram Nganyin) in Mildura region; extend Aboriginal youth mentoring program funding; continue Family Wellbeing Program with additional government funding; (b) development of program similar to Fresh Tracks using service model for clients with complex needs and lower attendance rates
Full text
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