Coroner's Court of Western Australia

Inquest into the Death of CHILD RM

Inquest into the Death of CHILD RM

Delivered on: 16 July 2020

Delivered at: Perth

Finding of: Coroner Jenkin

Recommendations: Yes

Recommendation No. 1

The Department should consider whether the Children and Community Services Act 2004 WA, should be amended to provide for a maximum secure care placement of greater than 42 days.

Recommendation No. 2

In order to adequately address the needs of young people with complex/extremely complex needs, including those transitioning from secure care, .the Department should fast-track the implementation of its proposed complex community care service (the Service). Given the obvious and urgent need for the Service, the current endorsed commencement date, namely the last quarter of 2023, is manifestly inadequate as is the Department's "accelerated" start date of July 2022 which is currently under consideration.

Recommendation No. 3

In order to ensure the cultural safety of children and staff at the Kath French Secure Care Centre (the Centre) and provide staff with access to a high level of cultural competence the Department should, as a matter of urgency, endorse the business case submitted by the Director, Secure Care on 24 January 2020 and take all necessary steps to employ a cultural therapeutic specialist at the Centre.

Orders/Rules: N/A

Suppression Order: Yes

Suppression of the deceased’s name from publication and any evidence likely to lead to the child’s identification, including the names of any siblings also in care that may be identified during the proceedings. The deceased is to be referred to as "Child RM".

Summary: Child RM died on 16 April 2017 from ligature compression of the neck (hanging), she was 17-years of age. At the time of her death, she was in the care of the Chief Executive Officer (CEO) of the Department of Communities (the Department).

Child RM first came to the attention of the Department of Communities in 2000 when she was 12-months old. In 2001, following an assessment by the Department, she was placed into foster care for 2 weeks before being returned to the care of her parents. In 2007 the Department was concerned about the inability of either of Child RM’s parents to provide her with a safe environment and she was removed from their care on 8 September 2008. Child RM came into the care of the CEO on 4 March 2009, when a Protection Order (until age 18 years) was made in the Children’s Court of Western Australia.

Between 2008 and 2011, Child RM was the subject of numerous out-of-home placements organised by the Department, including general carers, family carers and residential homes. These placements invariably broke down mainly because of Child RM’s increasingly challenging behaviours. When her placements broke down, Child RM tended to “self-select” placements with either her mother or her father, neither of which were approved carers by the Department. Between late 2011 and early 2012, the Department investigated concerns regarding Child RM being exposed to harm including historical sexual abuse, emotional harm and physical harm.

Between 2012 and January 2017, Child RM was admitted to the Kath French Secure Care Centre (the Centre) on four occasions. Children may be placed in “secure care” for periods of up to 42-days (up to 21-days initial placement and up to a further 21 days in exceptional circumstances), but only when they are at imminent risk to themselves and others and only then, where there are no other available options. The Centre provides a therapeutic time limited “circuit breaker” designed to stabilise the child’s behaviours.

While in secure care, Child RM was not drinking alcohol and she attended medical appointments and education sessions about self-care and safety. After leaving secure care for the last time, Child RM was referred to Indigo Junction in Midland, an agency that offers services to young people at significant risk of homelessness. After a few days at the service, Child RM left to live with her father on 24 February 2017.

During the evening on 15 April 2017, Child RM was with her boyfriend and her mother and a number of other people near the large screen adjacent to the State Library in Northbridge. Child RM and her boyfriend had been arguing and she had been drinking with some other girls. After Child RM’s boyfriend was arrested for disorderly conduct and then released, he and Child RM caught the bus in the direction of Child RM’s father’s home. At about 10.30 pm, Child RM and her boyfriend were observed fighting on the bus. The driver stopped and called Transperth security. As he got off the bus after it had stopped, Child RM’s boyfriend spat at the bus driver.

Police attended and arrested Child RM’s boyfriend. They repeatedly offered Child RM a lift to her father’s home but she declined. She said she had lived on the streets before and preferred to walk there. Although she had initially been agitated when her boyfriend was arrested, when police left Child RM at about 11.15 pm on 15 April 217, she appeared to be calm and seemed happy. Police had no concerns for her welfare.

Child RM was found by two members of the public at about 11.35 pm, hanging from a verge tree in Morley, with a garden hose around her neck. Emergency services were called and Child RM was taken to Sir Charles Gairdner Hospital, where despite the efforts of members of the public, the police and hospital staff, she could not be revived.

The Coroner found Child RM’s parents were not able to provide Child RM with a safe environment despite the fact that Child RM clearly wanted to spend time with them. The Coroner was satisfied that the Department of Communities did what it could to address Child RM’s complex needs but found that there missed opportunities where additional support from the Department may have altered Child RM’s life. The Coroner made three recommendations relating to the services provided to traumatised children who entre secure care.

Catch Words: Children in Care : Complex community care service : Cultural Therapeutic Specialist : Suicide


Last updated: 30-Jul-2020

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