TRIGGER WARNING:This story contains details that may be distressing to some readers
Multiple criminal offences may have been committed in relation to the suspected suicides of three teenage girls in Top End remote communities, the Northern Territory Coroner has said in an inquest report released on Tuesday.
The inquest examined the circumstances of the deaths of three teenage girls who died in 2016 and 2017: Keturah Mamarika aged 16 in Groote Eylandt; Layla Leering aged 15 in Bulla; and Fionica James aged 17 in Warruwi.
Presiding over the court, Judge Greg Cavanagh, has referred the investigations to NT Police for further investigation and potential prosecution.
“I believe that offences have been committed in connection with the deaths of Fionica Yarranganlagi James, Keturah Cheralyn Mamarika and Layla Leering and in accordance... I report my belief to the Commissioner of Police and the Director of Public Prosecutions,” said Judge Cavanagh.
The harrowing report detailed the lives of the three teenage girls. Judge Cavanagh said it was a national disgrace with the teenagers' lives marred by abuse, neglect and apathy.
"These children lived and died in conditions of violence, sexual molestation and despair,” he said in his findings.
"That these conditions continue to exist in an affluent country such as Australia is a disgrace."
Judge Cavanagh determined evidence was unable to confirm 16-year-old Keturah’s death was by suicide. She was found dead in her Groote Eylandt home in 2016.
Forensic evidence suggested she was raped shortly before her death, with an autopsy finding cuts, bruises and abrasions on her body consistent with sexual assault.
“Her family were evasive about what happened and police have not been able to determine who raped her or the circumstances of her death,” the report said.
The inquest heard that police spent too little time in the communities investigating the deaths, closing crime scenes hours after deaths, and in Keturah’s case, closed the inquiry the same day she died.
Police reported bruising and cuts on Fionica's body were consistent with older injuries but further investigation found they were recent.
“Police also overlooked the likely violence leading to Fionica’s visits to the Health Centre from October 2017 and the likely impact upon her of the threats to herself and her family in the early hours of the morning of the day she died,” the report said.
Northern Territory police collected more forensic evidence on multiple occasions nearly two years after her death at the request of the Coroner but failed to properly store the samples.
Sixteen-year-old Keturah Mamarika was found dead and with "significant vaginal injuries" at her mother's home at Umbakumba on Groote Eylandt in 2016.
Her death remains suspicious and the circumstances of her death remain open.
Judge Cavanagh described multiple agencies as “blind” after they failed to recognise and respond to the extreme trauma and distress the girls were under.
“The most unsettling aspect of this inquest has been the blindness of the government agencies to the obvious trauma suffered by these girls," Judge Cavanagh said in his findings.
“All of the usual red flags were there including sexual exploitation, STI’s, suspicious injuries, behavioural issues, disengagement from school and notifications to the child protection agency.”
The 82-page report detailed the traumatic lives of the girls including rape, sexual assault, family violence, depression and suicide attempts as well as their struggles with schooling.
Judge Cavanagh found multiple government agencies failed to recognise or address the toxic stress and trauma all three teenage girls were under.
There were multiple visits to the hospitals and health clinics due to suspected assaults, abuse and sexually transmitted diseases but ‘red flags’ went unheeded or were not followed up.
The coroner found the lives of Keturah, Layla and Fionica were profoundly “distressing” and “disturbing” in a country as wealthy as Australia.
The report detailed failures from the education department to engage the girls’ back into school and criticised suspected abuse and domestic violence notifications not being further investigated.
“The failure of government agencies to recognise their plight is disturbing,” Judge Cavanagh said.
Both the NT Police and NT Family Services, formerly the Department of Children and Families, said significant changes were made after internal reviews found cultural biases, insufficient engagements with communities and failures in reporting.
The coroner recommended community and child safety frameworks be legally required to improve cooperation and communication sharing between agencies.
Judge Cavanagh called for the Department of Education to work with families and young people in remote communities to ensure they are attending school.
“The problems faced by these girls are still apparent today and real action has to occur immediately,”
“The time for expressions of sorrow and promises of action in the future, commissions of inquiry and the like are long gone.”
Readers seeking support can contact Lifeline crisis support on 13 11 14, visit lifeline.org.au or find an Aboriginal Medical Service here. Resources for young Aboriginal and Torres Strait Islanders can be found at Headspace: Yarn Safe.