The findings of an 18-month inquiry into the deaths of 13 Aboriginal youths in Western Australia’s Kimberley region were delivered to a packed gallery at Perth Coroner’s Court today.
The inquest looked into suicides that occurred between November 2012 and March 2016, with the youngest being a 10-year-old girl in the remote town of Looma.
The death of the girl left the nation astounded and shortly after Ros Fogliani, Western Australian state coroner, announced a joint inquest into the 13 deaths which commenced in June 2017.
Ms Fogliani, determined 12 youths died as a result of suicide, with one death found to be suspicious. The coroner concluded that “considerable services already being provided to the region are not enough.”
“The situation in the Kimberley Region is dire and children and young persons have continued to die by suicide” she said.
The deaths occurred despite the combined efforts of service providers, increased governmental funding, awareness of cultural competency and numerous other initiatives implemented to avoid these preventable deaths, she said.
The findings called for services designed for the mainstream and then retrofitted for the region’s Indigenous communities to be reviewed, and also questioned if it was time to consider whether services “need to be co-designed in a completely different way”, with a foundational shift towards “cultural healing for Aboriginal communities.”
Talking to NITV News outside the coronial hearing, deputy chief executive for the Kimberley Aboriginal Medical Services (KAMS), Rob McPhee, welcomed the findings. adding agrees with the coroner adding that programs need to be moved away from mainstream initiatives and tailored more towards the wants of the Aboriginal communities.
“There is a lot of mainstream services that are trying to impose a particular model on the needs of the community and what we really need to do is work with community to really understand what are the needs and design the services to respond to those needs,” he said.
The report contained 42 recommendations, covering a range of areas including health care, education, drug and alcohol programs, through to a comprehensive adoption of the principles of self-determination and empowerment in all future works concerning Aboriginal people in Western Australia. Mr McPhee said he was “optimistic” the inquest would motivate change.
“We got families that are suffering,” he said.
“We got children that are still in situations that the coroner described, and we need to work with government to make sure the change does happen.”
But Wayne Barker, a Djugunand Jabirr Jabirr man who works as an administrator at the Kimberley Aboriginal Law and Cultural Centre, doesn’t completely agree.
“This is an echo, this has happened before, where's the appetites, where are our Indigenous leaders pounding on the door of the government… where's their culture responsibility to protect us as the First Nations people of this country,” Mr Barker told NITV News.
“Where's your signature, where is your fingerprint on this, stand up and deliver.”
What the inquest found
Their deaths were investigated as one group because there was similar circumstances surrounding each death.
Ms Fogliani said that each death had been shaped by intergenerational trauma and poverty, with some having being exposed to sexual abuse and others having lost a friend or family to suicide.
Inquest findings showed that most of the youths never had contact with the mental health services and were never diagnosed with mental health issues or with foetal alcohol spectrum disorder despite sufficient evidence some of the youth suffered from the disorder.
Most of them voiced suicidal ideation or intent to take their own lives prior to doing so.
"The deaths are profoundly tragic, collectively and individually," Ms Fogliani said.
The coroner said in her findings that friends and families did not know who to turn to when the child spoke out about self-harm or thoughts of suicide, bringing attention to the need to raise awareness of mental health within communities.
These mental health services must be professional, accessible and culturally appropriate, the inquest found.
The coroner found 42 recommendations which Health Minister Roger Cook said the state government will address in the coming weeks.
Mr Barker believes that we are distracted by other issues that don't draw close to the importance of saving our Indigenous youth.
“It sickens me that we are allowing our young people to take their lives."
"We have to listen, we can’t be distracted by other issues."
"If we can't make an impact in our own communities how can we make an impact nationally?"
“What more important than saving the lives of our children? I struggle to understand it… this is shameful, Australia is supposed to be a developed nation and we have to hang our heads in shame here.”
The Australian Bureau of Statistics found in December last year that Aboriginal children aged between five and 17 died from suicide-related deaths at five times the rate of non-Indigenous children.
Our history with inquests into suicide-related deaths in the Kimberley region
This is the fourth inquest to take place in ten years.
In 2008, Former WA Coroner Alastair Hope released his findings into 22 Indigenous young people suicides in the Kimberley region.
The findings showed there was an increase in self harm compared to non-Aboriginal people in the Kimberley.
Mr Hope also found that living conditions were disgraceful and there was an extreme lack of mental health services along with drug and alcohol care, which Ms Fogliani echoes in her 2019 findings.
“Many already suffer from fetal alcohol syndrome and unless major changes occur most will fail to obtain a basic education, most will never be employed and, from a medical perspective, they are likely to suffer poorer health and die younger than other Western Australians,” Mr Hope said in 2008.
The 2008 inquest revealed that the state provided $1.2 billion, in addition to Commonwealth funding, each year to Aboriginal people in Western Australia.
This fund was allocated to 22 government agencies under 16 different ministers.
“In spite of this allocation, conditions were worsening and the gap in well-being between Aboriginal and non-Aboriginal was a vast gulf,” Mr Hope said.
“The system is clearly flawed and in spite of a lack of results it appears that no individual or organisation in government has been held responsible for improving outcomes for Aboriginal people.”
Mr Hope handed down another inquest in 2011 into the deaths of five young Aboriginal men who all lost their lives within a year of each other, four to suicide and one to what was believed a overdose of his addiction to sniffing petrol.
Recommendations for both these inquests were not made or followed through, The Guardian reported.
The third inquest came in 2017 outlining that there had been 700 recommendations coming from 40 inquiries into Aboriginal youth suicide over the past 14 years.
It also found relating factors to what we are seeing today, family violence and child abuse.
The problems since 2008 have since remained, and are echoed through each coronial inquest.
Mr Barker, for one, wants to look beyond inquests and reports and put the issue into the hands of Indigenous people.
“Culture is the foundation and we have to take control of it ourselves and governments, successful governments, over the years and years have delivered zero for us,” he said.
“This is another inquest that we will beat our hearts and point to the words on paper but… are we going to really make a real difference?”