Finding into death of Ms KSI
Deceased
KS1
Demographics
22y, female
Date of death
2018-02-05
Finding date
2024-02-05
Cause of death
Complications of cutaneous burns
AI-generated summary
A 22-year-old woman from Afghanistan died from complications of severe burns (75%+ body surface area) sustained during self-immolation on 5 February 2018. She was experiencing family violence from her husband and in-laws despite an active Family Violence Intervention Order excluding her husband. The coroner identified critical service system failures: Safe Steps provided insufficient mental health support despite her expressing suicidal ideation and failed to conduct adequate risk assessments; Child Protection did not link her with culturally appropriate services, failed to adequately respond to disclosed violence by extended family members, and did not collaborate effectively with other services involved in her care including Maternal and Child Health Nurses. There was also a systemic issue regarding inadequate family violence crisis accommodation. Improved practice frameworks (MARAM, SAFER) have since been implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Family violence perpetrated by husband and extended family members including assaults
- Breach of Family Violence Intervention Order by husband who returned to residence
- Limited emergency accommodation options resulting in motel placement
- Social isolation and lack of family and community supports
- Immigration status tied to spouse creating vulnerability
- Inadequate mental health support and risk assessment by Safe Steps
- Lack of culturally appropriate services and support
- Inadequate information sharing and collaboration between Child Protection and other services
- Insufficient safety planning and risk assessment by Child Protection
- Threats to kill by extended family members not adequately addressed
Coroner's recommendations
- Safe Steps must ensure all assessment practitioners have skills to assess and refer promptly to appropriate services including mental health support, CALD support, and RAMP referrals
- Safe Steps must develop and implement a proactive case management approach using a trauma-informed framework
- Safe Steps policy regarding Child Protection notifications should be reviewed to ensure staff are aware of alternate communication methods
- All Safe Steps RAPID staff must be aware of their obligation to undertake effective assessments during contact
- Safe Steps staff require training in trauma-informed practice
- Safe Steps must review support to staff following critical incidents
- Safe Steps must review response to critical incidents with a quality improvement focus
- The Safe Steps board function and performance should be reviewed to ensure adequate oversight
- Increased investment in purpose-built family violence crisis accommodation to replace motel placements
- Enhanced social housing options for victim survivors of family violence
- Improved information sharing protocols between Child Protection and Maternal and Child Health services
- Mandatory MARAM training for Child Protection workforce with focus on risk assessment and perpetrator accountability
- Enhanced training for Child Protection in engaging culturally diverse families experiencing family violence
- Child Protection should establish systematic referral processes to culturally appropriate services for CALD families
- Development of safety planning protocols for families with family violence
Full text
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Source and disclaimer
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