Coroner's Court of Western Australia

Inquest into the Death of HLS (Subject to Suppression Order)

Delivered on: 26 April 2018

Delivered at: Perth

Finding of: Coroner Linton

Recommendations: Yes

I recommend that the WACHS continues to provide universal screening of, and support for, pregnant women for alcohol use and all children identified through that screening as being at risk of neurodevelopmental impairment on the basis of antenatal exposure to alcohol and/or early life trauma be assessed by a paediatrician for developmental and behavioural impairments at age 12 months and in the year prior to school entry.

Orders/Rules: N/A

Suppression Order: Yes

There are two suppressions order made in respect to this matter. The deceased’s name and the deceased’s friend who is referred to throughout the finding as WIC.

Summary: At the time of his death the deceased was in the care of the Department for Child Protection and Family Support, having been taken into care on 2 March 2011. Shortly after his birth the deceased had been diagnosed with severe Fetal Alcohol Syndrome. This was known so the Department when he came into care. He had an associated intellectual disability and a chronic solvent addition.

The deceased was identified as requiring a high level of supervision due to his absconding behaviours and solvent abuse. Special Purpose Subsidy funding was approved and the carers he was placed with worked for the organisation known as Life Without Barriers. After one unsuccessful placement, that broke down after the deceased absconded, the deceased was placed at La Djadarr Bay, a community on the Dampier Peninsula. The placement was considered to be “on country” and gave him opportunities to develop his cultural understanding and independent living and social skills. 

In the weeks prior to his death the deceased and another boy stole a car and absconded from La Djadarr Bay. They were found in Broome and eventually returned to La Djadarr Bay the day before the deceased’s death.

On 13 March 2013 police officers at Dampier Peninsula Police Station were contacted by Life Without Barriers who reported the deceased had gone missing. He had been seen walking out into the mangroves, which are crocodile infested. Given the serious concerns for the deceased’s safety, a search was commenced immediately. On 14 March 2013 the deceased’s body was found in thick mangrove approximately 5 km from La Djadarr Bay Community.  He had a severe leg injury consistent with a crocodile attack.

The emphasis in the inquest was on the deceased’s diagnosis of Fetal Alcohol Syndrome and what flowed as a consequence of that diagnosis in terms of his care needs. The Court heard evidence from two experts in the field of diagnosis and management of children with FASD in Western Australia. The Court explored the provision of universal screening of development and behavioural issues for children and providing support for pregnant women for alcohol use.  The Coroner made a recommendation that WACHS continue to provide universal screening of those being at risk of neurodevelopmental impairment on the basis of antenatal exposure to alcohol and/or early life trauma be assessed by a paediatrician for developmental and behavioural impairments at age 12 months and in the year prior to school entry.

The Coroner found the deceased died between 13 and 14 March 2013 at La Djadarr Bay, Dampier Peninsula, in circumstances consistent with immersion in a young man with traumatic amputation of the left foot and multiple soft tissue injuries, and death occurred by way of misadventure.

Catch Words: Screening of FASD : Training of Carers : Solvent Abuse : Misadventure.


Last updated: 1-Aug-2018

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