Coroners Act, 1996 [Section 26(1)] Western Australia Inquest into the deaths of: THIRTEEN CHILDREN AND YOUNG PERSONS IN THE KIMBERLEY REGION, WESTERN AUSTRALIA Warning: The contents of this finding may be particularly distressing to some readers. Aboriginal and Torres Strait Islander peoples are warned that this finding refers to multiple deaths of young persons in the Kimberley Region. References will be made to geographical locations however there will be no references to persons’ names, to avoid causing offence or further distress to some readers. Inquest into the deaths of thirteen children and young persons in the Kimberley Region, Western Australia Page 1. Coroners Act, 1996 [Section 26(1)] Western Australia RECORD OF INVESTIGATION INTO DEATH Ref Nos: 25/2017 I, Rosalinda Vincenza Clorinda Fogliani, State Coroner, having investigated the deaths of: Thirteen children and young persons in the Kimberley Region of Western Australia, with an Inquest held at Perth Coroners Court, Central Law Courts, 501 Hay Street, Perth 26 June - 4 July 2017, 4 September – 8 September 2017 and 12 September - 15 September 2017; Broome Court, Hamersley Street, Broome, 17 July - 20 July 2017; Fitzroy Crossing Court, McLarty Road Fitzroy Crossing 2 August - 4 August 2017; Kununurra Court, 96 Coolibah Drive Kununurra 14 August - 18 August 2017; and Halls Creek Court, Great Northern Highway Halls Creek 25 August 2017, find that the identity of the deceased persons were - Name suppressed, female child referred to in Case 1, and that death occurred on 8 January 2013 at Kalumburu as a result of Ligature Compression of the Neck (hanging); Name suppressed, male child referred to in Case 2, and that death occurred between 4 and 5 April 2015 at Broome as a result of Ligature Compression of the Neck (hanging); Name suppressed, young man referred to in Case 3, and that death occurred on 7 May 2015 at Broome as a result of Ligature Compression of the Neck (hanging); Name suppressed, female child referred to in Case 4, and that death occurred on 6 March 2016 at Looma Aboriginal Community as a result of Ligature Compression of the Neck (hanging); Inquest into the deaths of thirteen children and young persons in the Kimberley Region, Western Australia Page 2. Name suppressed, female child referred to in Case 5, and that death occurred between 14-15 February 2013 at bushland at Wyndham as a result of Ligature Compression of the Neck (hanging); Name suppressed, male child referred to in Case 6, and that death occurred between 7-8 January 2014 at Mud Springs Community via Kununurra as a result of Ligature Compression of the Neck (hanging); Name suppressed, male child referred to in Case 7, and that death occurred on 26 September 2014 at Kununurra as a result of Ligature Compression of the Neck (hanging); Name suppressed, male child referred to in Case 8, and that death occurred on 12 December 2014 at Kununurra as a result of Ligature Compression of the Neck (hanging); Name suppressed, young man referred to in Case 9, and that death occurred on 24 March 2016 at Mud Springs Aboriginal Community, Kununurra as a result of Ligature Compression of the Neck (hanging); Name suppressed, young man referred to in Case 10, and that death occurred between 19-20 November 2012 at Violet Valley Station via Warmun as a result of Ligature Compression of the Neck (hanging); Name suppressed, male child referred to in Case 11, and that death occurred between 11-12 January 2014 at Halls Creek as a result of Ligature Compression of the Neck (hanging); Name suppressed, young man referred to in Case 12, and that death occurred on 5 January 2015 near Wungu Community via Halls Creek as a result of Ligature Compression of the Neck (hanging), and Name suppressed, young man referred to in Case 13, and that death occurred on 22 May 2015 at Halls Creek as a result of Ligature Compression of the Neck (hanging) in the following circumstances: Inquest into the deaths of thirteen children and young persons in the Kimberley Region, Western Australia Page 3. Counsel Appearing : Mr Philip URQUHART counsel assisting the State Coroner Mr Sarouche RAZI, with Ms Hannah LEVY and Ms Carol WEI (Kimberley Community Legal Services (KCLS)) appearing on behalf of the families of the following children and young persons, namely: the aunt of the female child referred to in Case 1 (in collaboration with ALS); the mother of the male child referred to in Case 2 (in collaboration with ALS); the mother of the young man referred to in Case 3(in collaboration with ALS); the mother of the female child referred to in Case 4 (in collaboration with ALS); the father of the female child referred to in Case 5; the mother of the male child referred to in Case 7; the aunt of the male child referred to in Case 8; the aunt of the young man referred to in Case 9; the mother of the young man referred to in Case 10; the mother and aunt of the male child referred to in Case 11; the mother and brother of the young man referred to in Case 12; the sister of the young man referred to in Case 13 (in collaboration with ALS). At the time of filing their submissions, KCLS instructions were extended to include the families of all of the above. Mr Paul GAZIA with Ms Alice BARTER and Mr Alexander WALTERS (Aboriginal Legal Service (ALS)) appearing on behalf of the families of the following children and young persons, namely: the mother of the female child referred to in Case 1 (in collaboration with KCLS); the mother of the male child referred to in Case 2 (in collaboration with KCLS); the mother of the young man referred to in Case 3 (in collaboration with KCLS); the mother and aunt of the female child referred to in Case 4 (in collaboration with KCLS); the sister of the young man referred to in Case 13 (in collaboration with KCLS). Ms Carolyn THATCHER with Mr David HARWOOD and Ms Jennifer O’MEARA (State Solicitor’s Office (SSO)) appearing on behalf of the Department of Communities (incorporating the former Department of Child Protection and Family Support, Department of Housing and Regional Services Reform Unit); the Department of Premier and Cabinet (incorporating the former Department of Aboriginal Affairs); the Commissioner of Police; the Department of Justice (incorporating the former Department of Corrective Services); the Department of Education; the Department of Health; the WA Country Health Service; the office of the Chief Psychiatrist; the Mental Health Commission; the Director of Liquor Licensing; the Department of Local Government, Sport and Cultural Industries (incorporating the former Department of Racing, Gaming and Liquor). SUPPRESSION ORDERS Suppression of all the deceaseds’ names from publication and any evidence likely to lead to their identification (save that locations may be referred to). Suppression of evidence concerning the details of the children’s dangerous behaviour (Case 7) Inquest into the deaths of thirteen children and young persons in the Kimberley Region, Western Australia Page 4. Table of Contents RECORD OF INVESTIGATION INTO DEATH ....................................................................................... 2 SUPPRESSION ORDERS .................................................................................................................... 4 INTRODUCTION ............................................................................................................................... 8 THE KIMBERLEY REGION ................................................................................................................ 12 THE INQUEST ................................................................................................................................. 15 THE FAMILIES ................................................................................................................................. 16 SUICIDE AND CHILDREN ................................................................................................................. 19 ABORIGINAL SUICIDE ..................................................................................................................... 28 SUICIDE IN THE KIMBERLEY ........................................................................................................... 31 COMMUNITY VISITS ....................................................................................................................... 35 CONSULTATIONS WITH ABORIGINAL PERSONS ............................................................................ 37 INTERGENERATIONAL TRAUMA .................................................................................................... 45 CULTURAL CONTINUITY AND CULTURAL HEALING ....................................................................... 56 HEALTH SERVICES IN THE KIMBERLEY REGION ............................................................................. 60 MENTAL HEALTH SERVICES IN THE KIMBERLEY REGION ............................................................... 62 HOUSING SERVICES IN THE KIMBERLEY REGION ........................................................................... 68 EDUCATION SERVICES IN THE KIMBERLEY REGION ....................................................................... 73 POLICE PRESENCE IN THE KIMBERLEY REGION ............................................................................. 78 ALCOHOL RESTRICTIONS IN THE KIMBERLEY REGION ................................................................... 82 AMALGAMATION OF GOVERNMENT DEPARTMENTS ..................................................................