Coroner's Court of Western Australia

Inquest into the 13 Deaths of Children and Young Persons in the Kimberley Region

Inquest into the Deaths of 13 Children and Young Persons in the Kimberley Region

Delivered on : 7 February 2019

Delivered at : Perth

Finding of : State Coroner R V C Fogliani

Recommendations : Yes

Orders/Rules : N/A

Suppression Order : Yes

Suppression of all 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 (Case7).

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.


Summary : The State Coroner conducted an inquest hearing into 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, on 26 June - 4 July 2017, 4 September – 8 September 2017 and 12 September - 15 September 2017, Broome Court 17-20 July 2017; Fitzroy Crossing Court 2-4 August 2017, Kununurra Court 14-18 August 2017 and Halls Creek Court 25 August 2017.

The deaths of thirteen children and young persons in the Kimberley Region were investigated at the one Inquest because there were similar circumstances, life events, developmental experiences and behaviours that appear to have contributed to making them vulnerable to suicide.

The State Coroner found the cause of death for all thirteen cases was as a result of ligature compression of the neck (hanging) and of the thirteen deaths the State Coroner found twelve of the deceased persons died as a result of suicide and in one case an open finding was made.

The State Coroner made forty-two recommendations.

Catch Words : Aboriginal Suicide : Kimberley Suicides : Cultural Healing : Intergenerational Trauma

Last updated: 23-Mar-2020

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