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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".
Key points:
- 13 children and young people took their lives in WA's north in less than four years
- The coroner found "inter-generational trauma' was a factor in the deaths
- She has listed a suite of recommendations to tackle social root causes
The inquest investigated a cluster of 13 deaths which occurred in the state's Kimberley region in less than 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 intergenerational trauma".
She made 42 recommendations addressing a range of issues which she said would help target the root causes of the issues, including:
- Restrictions on the purchase of takeaway alcohol across the Kimberley
- A cashless debit card program to be offered to the entire Kimberley region
- Better screening and services for people with foetal alcohol spectrum disorder (FASD)
- A special adviser to be appointed on matters concerning Aboriginal children and young persons
- The WA Government to develop a state-wide Aboriginal cultural policy
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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."
Support services not adapted to Indigenous culture: Coroner
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.
She said the considerable services already being provided to the Kimberley region were not enough.
"The situation in the Kimberley Region is dire and children and young persons have continued to die by suicide, despite the valiant efforts of service providers," she said.
"[This is] despite the increased governmental funding, despite a better understanding of the importance of being culturally competent, and despite the numerous initiatives being implemented to avoid these preventable deaths."
She said services continued to be provided from a mainstream perspective, "adapted in an endeavour to fit into a culturally-relevant paradigm".
"It may be time to consider whether the services themselves need to be co-designed in a completely different way, that recognises at a foundational level, the need for a more collective and inclusive approach towards cultural healing for Aboriginal communities," she said.
'A lot of people have lost their family'
Marie from Fitzroy Crossing, who requested for her surname to be withheld, was one of a small group of family members who listened to the coroner's findings as they were streamed via video link to the Broome courthouse.
She said she wanted to better understand why her son had died.
"For myself, to hear what happened to my son, I want to know the truth," she said.
"He was a good bloke, he didn't hate anyone, why did somebody have to make him upset? And he left me, my son."
Marie said she did not think the coronial inquest would help reduce youth suicide in the Kimberley.
"No, I was hurting inside, and when I came out, the feeling of sorrow inside, I had to cry," she said.
"A lot of people have lost their family, have lost their loved ones like me."
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.
'We have to look to the optimism'
Labor Senator Pat Dodson said the findings contained a mix of both of despair and hope.
"It just reminds us that it's such a tragedy for young people in the Kimberley, [but] yet again we really have to look to the optimism in the coroner's recommendations," he said.
"The real necessity is to not only listen to first nations people, but to develop action plans and to address those matters at the regional level."
Senator Dodson said he was pleased the coroner had made note of the importance of including Indigenous people when devising responses to suicide.
"This is a welcome sign, from at least the coroner's insight into where the change ought to happen, but it will take political will, and commitment and resources," he said.
"Really the onus is on the Government to follow through with the co-design processes, involving local and regional leadership to find solutions and to act on those solutions."
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."
Senator Dodson said it was frustrating recommendations from the Hope inquiry had not been implemented.
"It always makes me a bit angry, I've been a royal commissioner, I've listened to the Hope inquiry, I see communities on a regular basis where there's frustration with the bureaucracy not listening," he said.
"Those more chronic matters that we just recite on a regular basis — like health, housing, education, overcrowding, domestic violence and child abuse — it's like a litany of things that just roll off our tongues these days, and we should never take them for granted."
While liquor restrictions and income management have been expanded, and millions of dollars have 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.
Topics: suicide, aboriginal, child-health-and-behaviour, courts-and-trials, death, perth-6000, broome-6725, derby-6728, fitzroy-crossing-6765, halls-creek-6770, kununurra-6743
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