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

13y · Female·complications of a head injury sustained when she deliberately stepped in front of an oncoming car

A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinicians. In the final 6 weeks before death, she had 8 ED attendances and 6 hospital admissions to the mental health unit. Critical gaps were identified: the Department of Communities failed to adequately assess referrals for family support services and delayed action; Bentley Family Clinic provided appropriate community care despite fragmentation from repeated hospital admissions and the patient's initial treatment reluctance; Perth Children's Hospital appropriately managed acute presentations but faced a significant service gap—there was no step-up/step-down facility available between discharge and community intensive programs like Touchstone, forcing unsafe rapid discharges to parents at breaking point. Long hospital stays are contraindicated in EUPD treatment. The coroner emphasised that intensive day programs and acute community response teams, combined with dedicated step-down facilities for under-16s, are essential to prevent similar deaths.