Inquest into the Death of Child J (Name Subject to Suppression Order)

Contributing factors

• foetal alcohol spectrum disorder with probable neurodevelopmental impairment
• early childhood trauma, neglect and abuse
• failed reunification with biological mother and father
• placement instability (34 living arrangements in 14 years)
• lack of continuity of care and multiple case managers (30 in 14 years)
• poor emotional regulation and impulse control
• impulsive response to first relationship breakdown
• inability to seek help or disclose distress
• limited mental health services in remote location
• disengagement from mental health services in Carnarvon
• lack of confiding relationship with stable adult

Coroner's recommendations

1. Improve continuity of care and reduce caseworker turnover in child protection services in the Kimberley
2. Develop comprehensive multidisciplinary neurodevelopmental assessment services in remote regions for early identification of FASD and other developmental impairments
3. Implement integrated child protection and preventative health service models
4. Provide trauma-informed care training to foster carers
5. Establish life story books for children in care with multiple placements
6. Reduce caseworker caseloads to enable more frequent contact and relationship building
7. Improve support for foster carers including respite care and housing assistance
8. Re-engage with mental health services when children return to regions after placement moves
9. Implement routine screening and monitoring for relationship breakdown in high-risk youth
10. Develop Regional Aboriginal Suicide Prevention Plans specific to the Kimberley
11. Enhance emotional self-regulation programs for children with FASD
12. Improve liaison between CAMHS, Department of Communities, and schools
13. Ensure health assessments are actioned promptly when referred