Inquest into the Death of HLS (Subject to Suppression Order)

Contributing factors

• Fetal Alcohol Syndrome with severe neurocognitive impairment affecting risk assessment and consequential thinking
• Developmental age estimated below 10 years despite chronological age of 15
• Impulsive decision-making and lack of executive function
• Geographical isolation and remoteness of placement
• Presence of large saltwater crocodiles in area
• Crocodile-infested tidal waters with king tide movement
• Limited formal training for carers in FASD management
• Tension between isolation needed for solvent safety and social/developmental needs

Coroner's recommendations

1. WACHS to continue universal screening of pregnant women for alcohol use and all children identified as at risk of neurodevelopmental impairment on the basis of antenatal exposure to alcohol and/or early life trauma be assessed by a paediatrician for developmental and behavioural impairments at age 12 months and in the year prior to school entry
2. Department for Child Protection to implement screening process for children entering care using child development screening tools, with consideration of Dr F.'s recommended approach and implementation of standardised screening tools in areas where FASD is known to be prevalent
3. Official workshops run by DCP once or twice a year with carers to educate them about FASD, early life trauma, how to recognise these conditions, and evidence-based strategies for support
4. Increased funding for service provision in remote communities for children with FASD and early life trauma
5. Greater training and capacity building for NDIS assessors to understand FASD and its functional implications
6. Consideration of making FASD diagnosis automatically trigger NDIS eligibility assessment, similar to autism diagnosis