Inquest into the Death of Kimberley Coronial Report

Contributing factors

• Alcohol abuse (16 of 21 self-harm deaths had blood alcohol >0.15%)
• Cannabis use (significant in majority of self-harm deaths)
• Severe socioeconomic deprivation
• Inadequate housing
• Food insecurity
• Unresolved grief and community trauma
• Mental health problems (undiagnosed/untreated psychosis)
• Lack of employment opportunities
• Foetal alcohol syndrome in children
• Truancy and educational failure
• Lack of mental health facilities in Kimberley
• Absence of government coordination/leadership
• Intergenerational disadvantage and poverty
• High disease burden
• Inadequate child protection resources

Coroner's recommendations

1. Identify an individual or organisation to lead efforts to close the gap between indigenous and non-indigenous wellbeing with power and resources to coordinate region by region throughout the Kimberley
2. Conduct assessment of sustainability of remote communities before major housing/infrastructure investment, taking account of practical, historical and cultural factors
3. Take positive action to employ Aboriginal people in government sector activities and upskill suitable local candidates
4. Encourage Aboriginal leadership and provide training where needed for participation in decision-making
5. Enable cross-departmental access to human resources and field workers' knowledge
6. Implement accountability system requiring officials to accept responsibility for targets with identified accounting of where funding is allocated
7. Restructure Department of Indigenous Affairs with leadership structure commanding respect, power to monitor other agencies, and adequate resourcing of regional offices
8. Create multi-function government offices in centres like Broome where Aboriginal people can access coordinated services
9. Ensure government housing is not reallocated in ways that disadvantage recruitment of vital regional workers such as Child Protection Workers
10. Ensure government agencies providing vital Kimberley services are not disadvantaged in attracting and retaining staff compared to other agencies
11. Introduce compulsory income management system and give Department for Child Protection ability to request it in cases of child neglect
12. Support Clontarf Foundation efforts and expand football academies to more Kimberley schools
13. Implement whole-of-government approach to addressing truancy and its causes with cross-departmental monitoring and resources
14. Provide remedial teaching to students attending school who have not achieved basic education levels for their ages
15. Do not withdraw CDEP system from communities unless alternative employment is achievable
16. Review CDEP system to improve supervision quality, expand hours worked, and link training with employment certificates
17. Future housing planning address particular wants/needs of residents including alternatives to nuclear family homes such as cluster housing
18. Fund Housing Department to provide basic furniture including beds to raise mattresses off floors with education on maintenance
19. Establish homemaker program involving Housing, Health and Child Protection departments to teach life skills and property maintenance
20. Consider means of limiting alcohol abuse impact including restricting takeaway full-strength alcohol and implementing voucher systems
21. Ensure Department of Indigenous Affairs and Leedal maintain communications so Fitzroy Crossing Trust beneficiaries receive maximum benefit
22. Review Department of Health staff allocation to Fitzroy Crossing Hospital in context of appalling community health
23. Give ongoing consideration to positive health programs including construction and operation of swimming pool in Fitzroy Crossing
24. Take immediate action to construct secure mental health facility at Broome Regional Hospital with 24/7 trained mental health services
25. Continue support for police policy of increased presence in remote locations and construction of adequately funded multi-function police facilities
26. Allocate greater resources to coordinating police alcohol and drug response for Kimberley District
27. Allocate high priority to detection and prosecution of illicit alcohol sales