Inquest into the Death of Child RK (Name Subject to Suppression Order)
Inquest into the Death of Child RK (Name Subject to Suppression Order)
Delivered on : 17 December 2025
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : Yes
Recommendation No. 1
In order to better address the complex psychiatric, psychological, and/or behavioural needs of children in the care of the CEO of the Department of Communities (Department), I recommend that with reference to the stepped model of services for children in care set out in the report of Dr Vineet Padmanabhan dated 24 October 2025 (see pages 11-13):
- The Child and Adolescent Health Service (CAHS) lead, in collaboration with the Department, and the Mental Health Commission, work to determine the feasibility of implementing a service to provide assertive mental health care for children in the care of the CEO of the Department; and
- The Department lead, in collaboration with the CAHS, work to examine the feasibility of adopting a new dedicated secure therapeutic facility model of service for children in the care of the CEO of the Department.
Recommendation No. 2
The Department of Communities should, in consultation with the Young People with Exceptionally Complex Needs service’s key stakeholders and agency leads, consider the feasibility of broadening the program’s remit beyond its current eligibility criteria, so that it could serve as an escalation point for cases involving children in care such as Child RK.
Recommendation No. 3
The Department of Communities should provide additional training to caseworkers (and other relevant staff) to enable them to better understand the complex psychological, behavioural, and substance issues needs of many children in care and to better identify trauma behaviours that may place those children at increased risk of self-harm or suicide.
Orders/Rules : No
Suppression Order :
There is to be no reporting or publication of the deceased’s name and/or any evidence likely to lead to the deceased’s identification, including but not limited to the names of any of the deceased’s siblings. The deceased is to be referred to as “Child RK”.
Summary : Child RK died in the early hours of 20 April 2022, at a therapeutic residential group home in Swan View from ligature compression of the neck. Child RK was 14-years of age. At all relevant times, Child RK was in the care of the Director General of the Department of Communities (the Department). Consequently, the coroner made an order supressing Child RK’s name, and any evidence that might lead to her identification.
At about midnight on 20 April 2022, Child RK was listening to music in her bedroom at the therapeutic residential home she was living in. Care workers asked Child RK to turn her music down as it was too loud, which she did so without complaint. A short time later Child RK made a post on social media, but later incoming messages do not appear to have been read by her.
At about 9.30 am on 20 April 2022, care workers knocked on Child RK’s bedroom door to wake her up for an appointment, but there was no response. A short time later, another care worker went to check on Child RK and found her hanging with a mobile charger cable around her neck that was tied to the door handle.
Emergency services were called, and Child RK was cut down and placed on her bed. Ambulance officers arrived a short time later and confirmed that Child RK was deceased.
The coroner noted that Child RK was taken into care in 2012 when she was 4 years of age, on the grounds of substantiated neglect. Whilst she was “in care” Child RK was placed in several foster care placements, including one that lasted for a number of years.
After carefully considering the available evidence, the coroner concluded that there were missed opportunities in Child RK’s care and supervision could and should have been improved. However, the coroner was not able to conclude that any particular action at any particular time would necessarily have altered the outcome in Child RK’s case.
The coroner made three recommendations relating to greater integration of available services, and enhanced training for caseworkers respectively.
Catch Words : Child in Care : Missed Opportunities : Hanging : Suicide
Last updated: 29 December 2025