Coroner's Court of Western Australia

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

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

Delivered on : 20 November 2017

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

The deceased’s name and any evidence likely to lead to the deceased’s identification are suppressed from publication. The deceased is to be referred to as JDC..

Summary : At the time of death the deceased was almost 18 years old and was in the care of the Chief Executive Officer of the Department for Child Protection and Family Support.

The focus of the inquest was primarily on the care provided to the deceased while in the care of the Department in the final years prior to death, as well as the circumstances of her death.

The Court heard evidence that the deceased was placed into the care of the Department at a very early age, with allegations of abuse and neglect involving family members. The Department’s records indicate that the deceased from about the age of 13 years was engaging in risky behaviour and lifestyle choices, including drug and alcohol misuse, criminal behaviour and an intermittent dangerous relationship with a violent older man.  For most of the deceased’s teenage years she was not engaged in school or training and appeared to have no real structure or boundaries in her life.  The Department’s representative advised the Court that despite the Department offering the deceased placements and support the deceased elected to self-select where to live.

On 19 April 2012 the deceased was at a party where she had been drinking alcohol. The deceased decided to leave the party and followed her uncle to his car, she asked him for a lift to Roebourne.  The deceased’s uncle told the deceased he was too drunk to drive.  The deceased’s uncle then got into the passenger side of his car, he intended to lie down so he could go to sleep.  The deceased has then got into the driver’s seat of her uncle’s car.  The keys to the vehicle were in the ignition of the car and the deceased has been able to start the car.  The deceased commenced to drive the car towards Roebourne while the deceased’s uncle fell asleep.  The car was observed by a witness to be travelling along a straight stretch of road, about 5 kilometres from Roebourne when it suddenly went from left to right as if the car was swerving.  The rear lights of the vehicle then rotated in a clockwise direction as it began to roll over several times.  The vehicle eventually landed upside down on the right hand side of the road with the front end facing away from Roebourne.

The witnesses to the vehicle crash rendered assistance at the scene and called police. The deceased was conveyed by ambulance to the Roebourne Hospital, examined and was transferred to the Nickol Bay Hospital in Karratha.  The deceased was examined and found to have head wounds to her right forehead and right cheek and a degloving injuring to the left parietal area of her scalp, as well as marked swelling around her right eye and right side of her face.  She also had a deep laceration to her knee, laceration to her outer left ankle and minor abrasions to her torso.  The deceased’s case was discussed with a Trauma Registrar at Royal Perth Hospital and it was agreed the deceased should be transferred by Royal Flying Doctor Service to Royal Perth Hospital.

The deceased arrived at Royal Perth Hospital in the early evening of 19 April 2012 where she was treated and underwent surgery the following day. The deceased remained at Royal Perth Hospital where she received ongoing treatment.  The deceased developed a serious infection, which was complicated by her previously undiagnosed diabetes.  Despite intensive treatment she succumbed to the infection and died on 22 May 2012.

The Coroner was satisfied that there was nothing that the Department did or failed to do that contributed to the deceased’s death. The deceased’s diabetes may have been able to be diagnosed at an earlier stage, if she had attended medical reviews, but even if diagnosed it was not clear whether she would have been able to manage her condition given her prior lifestyle choices.

Catch Words : Undiagnosed diabetes : Unwillingness to follow medical advice : Person held in care : Accident

Last updated: 30-Apr-2019

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