Updated
Western Australia’s coroner has described the deaths of more than a dozen young Indigenous people aged as young as 10 as “profoundly tragic, individually and collectively”.
The inquest investigated a cluster of 13 deaths which occurred in the state’s Kimberley region in under four years, including five children aged between 10 and 13.
Handing down her findings, coroner Ros Fogliani said she had concluded 12 of the deaths were by suicide, while she made an open finding in one of the cases.
Ms Fogliani said the deaths had been shaped by “the crushing effects of inter-generational trauma”.
She made 42 recommendations addressing a range of issues which she said would help target the root causes of the issues.
These included:
- More attention being given to preventing foetal alcohol syndrome disorder, which can lead to children developing mental health issues
- Broadening liquor restrictions across the region
- A voluntary cashless welfare card to deal with the issue of “sly grogging”
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Ms Fogliani said government-run suicide prevention programs were too often retrofitted to work in Indigenous communities without being culturally sensitive and the government needed to rethink how to roll out these services.
The death of a 10-year-old girl in March 2016 followed a spate of suicides in the Kimberley which prompted the coronial investigation.
“It is devastating that a child of 10 would even consider taking their own life,” WA’s then-mental health minister Helen Morton said at the time.
“We have a responsibility to make sure children are safe, no matter where they live.”
One of WA’s biggest inquests
The inquiry began in Perth and was one of the largest and most complex in the state’s recent history, with Ms Fogliani travelling to Broome, Kununurra, Fitzroy Crossing and Halls Creek to hear from affected communities.
The hearings highlighted the complexity of the problem, with witnesses testifying to confusion and overlap between government agencies responsible for suicide prevention, children using alcohol to escape “horrific” circumstances, and key factors — such as foetal alcohol spectrum disorder — not being taken seriously.
Hearings in Broome were rocked by the suicide of a teenage boy, and Kimberley MP Josie Farrer labelled the inquest a mockery over what she said was a lack of both interpreting services and cultural understanding.
Since the hearings finished, another two teenage girls have taken their own lives in the communities of Halls Creek and Warmun.
Little change in decade since previous inquest
Many of today’s findings echo those of a 2008 inquest into 22 Aboriginal deaths across the Kimberley, serving as a stark reminder of the lack of any significant progress.
Former coroner Alistair Hope’s damning report made 27 recommendations, the response to which was within Ms Fogliani’s brief to assess.
Mr Hope highlighted the widespread abuse of alcohol, poor conditions in remote communities and a lack of accountability and leadership from Government as key factors contributing to young people taking their own lives.
“The system put in place to address Aboriginal living conditions in the Kimberley should involve a system of accountability,” Mr Hope said.
“This system should also identify what proportion of the money has been used in administrative costs against provision of services.”
While liquor restrictions and income management have been expanded, and millions of dollars has been committed to suicide prevention in the Kimberley, young people continue to take their own lives.
A report published in the Medical Journal of Australia found 102 of the 125 people who killed themselves in the Kimberley between 2006 and 2016 were indigenous.
Of those, 70 per cent had never been referred to a mental health service, while the report’s authors suggested the rate would double by the end of the decade.
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