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

15y · Male·ligature compression of the neck (hanging)

Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist mental health and paediatric services, he lacked continuity of care (30 case managers in 14 years). Missed opportunities included: incomplete 2009 Princess Margaret Hospital assessment; disengagement from mental health services in Carnarvon 2014; and failure to re-engage with mental health when he returned to Broome, despite previous suicidal ideation. The death highlights systemic issues in remote out-of-home care: staff attrition, resource scarcity, placement instability, and the profound effects of early trauma and FASD on emotional regulation and impulse control. Prevention would have required earlier comprehensive neurodevelopmental assessment, continuity of therapeutic relationships, and integrated child protection and health services.