Government department heads in the NT have repeated promises to retrain staff, improve their record-keeping and coordinate support for children who sniff solvents.
- NT Health says it will be a “priority” to ensure workers understand guidelines
- The Department of Education has committed to better record-keeping
- Both departments and Territory Families say a new collaboration will also help deliver better outcomes
Warning: This story contains details which may be distressing for some readers.
The commitments were made on day four of a joint coronial inquest into the deaths of 12-year-old Master W, 13-year-old Master JK and 17-year-old Ms B, who died in separate Arnhem Land communities in 2018 and 2019.
Counsel assisting the coroner, Kelvin Currie, told the court the children’s deaths bore similarities to a 2017 inquest involving Mr Laurie, who for cultural reasons is known by only his last name.
Mr Currie was concerned the departments were repeating mistakes made three years ago.
“[Mr Laurie] was case managed or monitored until they got severe injuries and in this case, the children seemed to be case managed or monitored until they died,” Mr Currie said.
One of the issues raised in the 2017 inquest was an “immediate need” to make sure staff were trained in and understood the Volatile Substance Abuse Prevention Act.
This week’s inquest has heard — on multiple occasions — that health staff did not “understand” their legal obligations to raise cases involving patients at “high risk of severe harm” with the Chief Health Officer.
“When do you think the law and the guidelines would be abided by, by what time?” Mr Currie asked.
NT Health’s senior director for mental health, alcohol and other drugs Cecelia Gore objected to the question, and said the guidelines were being adhered to “most of the time”.
Ms Gore went on to say it would be a “priority” for the department to make sure workers were familiar with the act.
She said following the inquest, there “can be no doubt that people will be aware” of the guidelines relating to volatile substance abuse.
Another issue flagged in the 2017 inquest was a lack of treatment programs which were available to help “angry and potentially violent petrol sniffers”.
Ms B attended and was ejected from BushMob on two occasions — the first in 2016 and the second in 2018 — for behavioural issues.
She took her own life four months after the second occasion.
Ms Gore said NT Health had been working with service providers to ensure they make “every effort to provide a place for someone as referred”.
She said in 2019, 14 people had been ejected from treatment facilities across the Northern Territory due to poor behaviour.
She said so far in 2020, nobody had been kicked out due to behavioural issues.
“There are always going to be times when a service, for the safety of its staff and other clients’ needs to hold a place of discretion around not continuing to hold someone,” Ms Gore said.
“We haven’t had that happen in the last period of time.”
Education bureaucrats take the stand
Shane Dexter, the general manager of quality school systems and support with Department of Education, said a review into the children’s cases found “practices and policies at the time were in some respects unsatisfactory”.
“Unfortunately, the department was not successful in supporting these children to come to school regularly or to get good outcomes and for that we are truly sorry,” he said.
Mr Dexter went on to say the review highlighted a number of issues — including poor record-keeping and interventions which were “almost entirely compliance driven as opposed to engagement driven”.
“One of the most significant findings of my review is that records that I expected to find were not located and that means they weren’t made or weren’t kept appropriately,” he said.
Mr Dexter said Ms B’s earlier school records showed her progress and it was an “alarming red flag” for him when the child’s results begun to decline, but there was no evidence of an intervention.
“We could have had better impact on Ms B’s life,” Mr Dexter told the court.
But Mr Dexter said since his review, the department had started to overhaul its record-keeping and was looking at more proactive ways to keep at-risk children engaged in school.
He said this included building stronger relationships with families, linking at-risk kids with support services and making efforts to understand why students were not engaging with school or certain classes.
Karen Broadfoot told the court the department she works for, Territory Families, had started to focus on “cumulative harm” since an audit on 2017.
She explained this meant not just looking at each reported incident in isolation, but looking at past reports as well.
All three executives also said the newly developed local multi-agency community child safety teams, set up in May, would deliver better coordinated responses between the departments.