Coroner slams departmental failings in children’s deaths
WARNING: This story contains the names Indigenous children who have died.
THE "conditions of violence, sexual molestation and despair" in the lives of six children who died preventable deaths and the repeated failure of government agencies to intervene have been excoriated in damning Coronial findings handed down on Tuesday.
Territory Coroner Greg Cavanagh this year held joint inquests into the deaths of three children by suicide and three others after a history of substance abuse in remote NT communities and has now called for urgent action in response.
"That these conditions continue to exist in an affluent country such as Australia is a disgrace," he said.
Following the first inquest into the deaths of Cheralyn Mamarika, 16, Layla "Gulum" Leering, 15, and Fionica James, 17, Mr Cavanagh said none of the recommendations from previous inquiries into similar deaths had "gained any prominence or sustained action".
"The most unsettling aspect of this inquest has been the blindness of the government agencies to the obvious trauma suffered by these girls," he said.
"All of the usual red flags were there including sexual exploitation, STI's, suspicious injuries, behavioural issues, disengagement from school and notifications to the child protection agency.
"It is tragic and frustrating that the lessons of the past have gained so little traction."
As a result, Mr Cavanagh recommended a newly established Multi-Agency Community and Child Safety Framework be legislated "so as to ensure mandatory co-operation, co-ordination and information sharing in a timely manner".
"The problems faced by these girls are still apparent today and real action has to occur immediately," he said.
"The time for expressions of sorrow and promises of action in the future, commissions of inquiry and the like are long gone. I implore action rather than words."
The second inquiry probed the deaths of Miss B, 17, Master W, 12 and Master JK, 13, whom Mr Cavanagh said equally "received no genuine assistance or support", slamming the Health Department for continuing to flout the law in its failure to support them.
"Not once, in the two years that the assessors 'monitored' and 'case managed' Master JK was there compliance with the act and guidelines," he said.
"He was deprived of everything the act sought to provide so as to mitigate the risks of the severe harm from the activity in which he was engaged and from which he died."
Mr Cavanagh said despite a similar finding in a 2017 inquest that staff were in breach of the law, the same processes were still in place.
"It is tragic and frustrating that almost all of the issues and comments three years ago are equally applicable to these cases," he said.
"In my view the refusal or inability of the Top End Health Service to change its unlawful practices contributed to these children's deaths."
Mr Cavanagh said what little had changed in the past 15 years had "made no detectable difference".
"I am distressed that the same issues and lack of action I witnessed in 2005 and 2017 are still so evident today," he said.
"It is not generally considered necessary to recommend that a government agency comply with their legal obligations. However, in my opinion it is necessary that I make such a recommendation for a second time."
Mr Cavanagh was especially critical of the police response in relation to the three suicide deaths and expressed his belief that crimes had been committed in relation to each.
*For 24-hour domestic violence and sexual violence support call the national hotline 1800RESPECT on 1800 737 732 or MensLine on 1800 600 636. The Suicide Call Back service is on 1300 659 467.
Originally published as Coroner slams departmental failings in children's preventable deaths