Coronial
WAother

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

Deceased

Child RK

Demographics

14y, female

Coroner

Coroner Jenkin

Date of death

2022-04-20

Finding date

2025-12-17

Cause of death

ligature compression of the neck (hanging); suicide

AI-generated summary

A 14-year-old girl in state care (Child RK) died by suicide on 20 April 2022. She had complex presentations stemming from early childhood trauma, including attachment difficulties, emotional dysregulation, self-harm, suicidal ideation, substance misuse, and school disengagement. The coroner identified multiple missed opportunities: lack of complex case conferences despite escalating risk; failure to respond assertively to her friend's suicide in June 2021; inadequate follow-up after Crisis Connect assessments; failure to escalate her disengagement from school and counselling; and lack of care plan reviews before major placement changes. While the coroner found adequate general supervision by Department caseworkers, there was insufficient awareness of the cumulative negative impact of 'red flags' and limited integration between child protection and mental health services. The coroner found the death not preventable with certainty, but noted a more proactive, integrated response at key moments of deterioration might have improved support and reduced fatality risk. Key recommendations include implementing a stepped mental health care model, broadening escalation pathways, and providing additional training to caseworkers on identifying children at risk of self-harm and suicide.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrypsychologypaediatricsgeneral practice

Error types

communicationsystemdelay

Drugs involved

melatonindiazepammethamphetaminetobaccoalcoholcocainehallucinogens

Clinical conditions

complex post-traumatic stress disorderemotionally unstable personality disorder traits (borderline type)attachment disorderself-harmsuicidal ideationdepression and anxietyemotional and behavioural dysregulationsubstance use disorder

Contributing factors

  • complex post-traumatic stress disorder from early childhood trauma
  • attachment disruptions and multiple placement failures
  • disengagement from school and psychological counselling
  • death by suicide of close peer friend in June 2021
  • suicidal ideation and escalating self-harm behaviour
  • substance misuse (polysubstance use including methylamphetamine)
  • anxiety about placement changes
  • lack of complex case conferences despite escalating risk
  • failure to escalate red flag symptoms to mental health services
  • inadequate follow-up after Crisis Connect assessment
  • lack of care plan reviews before major placement changes
  • limited integration between child protection and mental health services
  • insufficient awareness by caseworkers of cumulative impact of risk factors

Coroner's recommendations

  1. The Child and Adolescent Health Service (CAHS) lead, in collaboration with the Department and the Mental Health Commission, work to determine the feasibility of implementing a service to provide assertive mental health care for children in the care of the CEO of the Department; and the Department lead, in collaboration with CAHS, work to examine the feasibility of adopting a new dedicated secure therapeutic facility model of service for children in the care of the CEO of the Department
  2. The Department of Communities should, in consultation with the Young People with Exceptionally Complex Needs service's key stakeholders and agency leads, consider the feasibility of broadening the program's remit beyond its current eligibility criteria, so that it could serve as an escalation point for cases involving children in care
  3. The Department of Communities should provide additional training to caseworkers and other relevant staff to enable them to better understand the complex psychological, behavioural, and substance issues of many children in care and to better identify trauma behaviours that may place those children at increased risk of self-harm or suicide
Full text
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