Inquest into the death of Kunmanara Forbes

15y · Female·Hanging (self-inflicted)

A 15-year-old Aboriginal girl in a remote Central Australian community died by suicide following a year marked by petrol sniffing, sexual abuse concerns, and reported suicide attempts. She suffered multiple sexually transmitted infections diagnosed at age 13 but medical records were not adequately reviewed during child protection assessments. Despite referrals between police and family services, no coordinated case conference occurred and critical information was not consolidated. A suicide attempt in August 2006 should have triggered mental health intervention, which did not occur. The coroner found FACS had responsibility to 'pull the case together' but failed to do so. Significant delays in the coronial investigation (over 2 years) compromised fact-finding. Key failures included poor inter-agency communication, inadequate review of medical evidence, and no targeted adolescent health services in the jurisdiction.