Inquest into the 13 Deaths of Children and Young Persons in the Kimberley Region

Contributing factors

• intergenerational trauma
• exposure to domestic violence
• alcohol abuse in home environment
• poor physical health including failure to thrive
• inadequate housing and overcrowding
• poor school attendance
• absence of mental health assessment
• normalisation of self-harm behaviour
• previous suicidal ideation not escalated
• substance abuse (alcohol and cannabis)
• family history of suicide
• delayed mental health referrals
• inadequate child protection assessments

Coroner's recommendations

1. Universal screening for FASD at infant health assessments and upon child entering child protection or justice system
2. Neurodevelopmental impairment incorporating FASD criteria be recognised as disability within NDIS
3. Consideration of Medicare item numbers for FASD diagnosis and assessment
4. Additional funding for primary care services in high burden areas for neurodevelopmental impairment diagnosis and therapy
5. Government funding to extend 'Making FASD History' project to other regional centres in Kimberley
6. Education campaigns in secondary schools on dangers of alcohol during pregnancy and FASD prevalence
7. Appointment of Special Advisor or Commissioner for Aboriginal children and young persons
8. Restrictions on purchase of take-away alcohol across entire Kimberley Region after consultation with communities
9. Assessment of feasibility of Banned Drinker Register modelled on therapeutic support
10. Proper resourcing of police to enforce sly grogging provisions
11. Recurrent funding for town-based patrols in Kimberley for diversionary alcohol services
12. Appointment of Local Area Co-ordinators or Family Advocates in Kimberley to assist families accessing services
13. Consideration of funding and assessment of feasibility of short-term accommodation in Kununurra for visiting Aboriginal persons
14. Continuation and extension of Transitional Housing Project to other town sites in Kimberley
15. Ensure Aboriginal persons in public/transitional housing not disadvantaged if household income exceeds threshold
16. Extension of Yiriman Project or similar model across Kimberley with guaranteed longer-term funding
17. Continued consultation with Aboriginal communities on strategies addressing suicide with community co-design
18. Measures to increase reporting and maintenance of domestic violence complaints including visually recorded statements
19. Cultural competency training for service providers co-designed with Aboriginal persons on trauma and FASD effects
20. Training for child protection workers and school staff in suicide intervention and prevention
21. Continued efforts to employ Aboriginal persons in health, education, child protection and police with bridging courses where necessary
22. Consideration of extending voluntary cashless debit card program to entire Kimberley Region
23. Expansion of video-conferencing for mental health assessments throughout Kimberley including after-hours service
24. Support for traditional cultural healing methods working collaboratively with western-style mental health treatment
25. Development of cultural healing projects incorporating on-country programs
26. Implementation of trauma-informed care and treatment across services
27. Holistic approach to alcohol, drugs and mental health addressing upstream factors
28. Development of mental health facility in East Kimberley
29. Preventative strategies and support for new parents
30. Provision of recreational facilities in communities
31. Employment of mental health clinician for Halls Creek
32. Expansion of Adopt-a-Cop community program
33. Expansion of Elders' Reference Group
34. Alcohol and drug rehabilitation programs for children and young persons
35. Expansion of Kindylink early learning program
36. Development of re-engagement classrooms for disengaged students
37. Implementation of school vocational programs
38. Aboriginal language classes in schools
39. Linking Yiriman Project to schools
40. Establishment of residential colleges for secondary students
41. Improved remuneration for CEOs of Aboriginal communities
42. Implementation of mutually agreed outcomes framework