Deceased
Aluel Ajak
Demographics
9y, female
Coroner
Coroner David Ryan
Date of death
2023-07-05
Finding date
2025-07-28
Cause of death
Multiple injuries sustained in a motor vehicle incident (pedestrian)
AI-generated summary
Aluel Ajak, a 9-year-old girl with autism spectrum disorder, severe developmental delay, and moderate intellectual disability, died from injuries sustained when struck by a motor vehicle after absconding from her home. She had a documented history of wandering behaviour and lived in public housing on a busy main road with a low-lying fence she could climb. Her mother made three transfer applications to Homes Victoria over several years, supported by her paediatrician's letters citing specific safety concerns. The coroner found unacceptable delays in processing these applications despite awareness of her extreme vulnerability. While the death resulted from tragic accident rather than clinical error, systemic failures in housing and disability support coordination meant safety modifications that could have reduced her risk of absconding were not implemented. Key lessons include the importance of urgent processing of accommodation requests for vulnerable children with documented safety risks, effective inter-agency coordination between housing and disability services, and proactive mitigation strategies while awaiting permanent housing solutions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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