Inquest into the Death of Child RK (Name Subject to Suppression Order)
Demographics
14y, female
Date of death
2022-04-20
Finding date
2025-12-17
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
Child RK, aged 14, died by suicide while in Department of Communities care at a therapeutic residential group home on 20 April 2022. She had Complex PTSD from childhood trauma and presented multiple times to emergency departments with suicidal ideation and self-harm from December 2021. The coroner found missed opportunities in her care: inadequate case conferences between child protection and mental health services, poor coordination across agencies, failure to escalate her disengagement from school and psychology, and insufficient follow-up after psychiatric assessments. Her treating psychologist had recommended a case conference about placement concerns; her final psychiatrist appointment was scheduled for the day she died. While acknowledging suicide's unpredictability, the coroner found that more proactive, integrated service responses at key moments of deterioration might have reduced risk. She recommended establishing assertive mental health care for children in care, broadening complex needs coordination mechanisms, and providing caseworkers with training on trauma-informed care and suicide risk identification.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Complex post-traumatic stress disorder from early childhood trauma
- Disengagement from school from August 2020
- Disengagement from psychological counselling by March 2021
- Death by suicide of close friend in June 2021
- Suicidal ideation and self-harming behaviour
- Repeated foster care placement breakdowns
- Placement instability and multiple care arrangements
- Lack of assertive mental health follow-up
- Poor coordination between child protection, mental health, and education services
- Inadequate escalation of risk factors
- Repeated absconding from residential care
- Polysubstance use history
- Anxiety about placement changes and disrupted attachments
Coroner's recommendations
- CAHS lead, in collaboration with the Department and 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 of Communities
- 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
- Department of Communities consider the feasibility of broadening the Young People With Exceptionally Complex Needs service's remit beyond its current eligibility criteria to serve as an escalation point for cases involving children in care
- Department of Communities provide additional training to caseworkers and other relevant staff to enable them to better understand the complex psychological, behavioural, and substance use needs of children in care and to better identify trauma behaviours that may place those children at increased risk of self-harm or suicide
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