Grieving families ask coroner to find out ‘what really happened’ in NT sniffing inquest
The family of a 17-year-old girl who died by suicide five years after she began petrol sniffing say her loss to them is unimaginable.
- The three key government agencies have admitted serious mistakes and failings
- The court heard there were similarities between this inquest and one in 2017
- On Monday, the NT coroner will hear final submissions
Warning: This story contains details which may be distressing for some readers.
Yesterday was the last full day of evidence at the 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.
The children’s families requested their full names not be used.
Ms B’s grandfather read a statement to the court on behalf of her family.
“When she passed away all the family was affected,” he said.
“Imagine losing a young one … it hurts right down.
“When young people pass away like this it is not their time to go.”
Ms B’s grandfather told the court the family wanted to know “what really happened and how it happened”.
“That will make the family’s heart settled. We hope this inquest will make it stop so it doesn’t happen to other girls and young people,” he said.
Ms B’s grandfather also said they needed community-based men and woman’s sheds to provide a safe space for children to speak with their elders about their worries.
“Community-based place so young people are not worried they would be sent away if they ask for help,” the grandfather explained.
“When the intervention happened it took away our rights and the responsibility to teach our children like our forefathers did.
“We can stop this spiral.”
As the inquest wraps up, here’s what we’ve learned so far.
Why are they being held together?
Like it did last month, the coroner’s office is looking at the three deaths together to investigate what it suggests are systemic failings that let these children down.
In these cases, all three were sniffing solvents for a long time and from a very young age — Master JK started sniffing bug spray at 8, Ms B was 12 when police found her sniffing petrol and Master W was seen sniffing aviation fuel at 11.
They were also all subject to notifications to Territory Families and had poor school attendances — with JK only attending classes two or three times a year from the age of 12.
Two of the kids — Master W and Ms B — were ejected from rehab for poor behaviour and sent back to their communities with little support.
How is this similar to the Laurie Inquest?
More than once, witnesses were asked if anything had been learned from the inquest into the death of a 24-year-old man held just three years ago.
Counsel assisting the coroner Kelvin Currie has made a number of links between this inquest and the one in 2017.
The 2017 inquest probed the death of Mr Laurie, known by his last name only for cultural reasons, who also sniffed solvents for a long time.
That inquest found health department staff didn’t understand the NT law around petrol sniffing, which requires them to refer high-risk cases up so the Chief Health Officer can decide what should be done.
But this week’s inquest heard staff — even at a top level — didn’t understand the law.
None of the three children ever had a treatment plan in place or had their cases elevated with the CHO.
Another issue flagged in the 2017 inquest was a lack of treatment programs which were available to help “angry and potentially violent petrol sniffers”.
Master W was expelled from rehabilitation for fighting and property damage. Ms B attended and was ejected from BushMob on two occasions — the first in 2016 and the second in 2018 — for behavioural issues.
What did the Government say?
The three key government agencies involved in the lives of children admitted serious mistakes and failings.
Territory Families northern region director Karen Broadfoot told the court it was a “significant failure” the organisation did not investigate allegations 12-year-old Ms B had been raped by someone living in the same house, later testing positive to an STD.
All three kids were the subject of multiple child protection notifications, and Ms Broadfoot conceded there were reports involving Ms B which were “screened out” and should have been investigated.
Shane Dexter from the NT Department of Education also admitted his department also missed on on “critical” opportunities to intervene in the lives of all three children.
His submission to the inquest said records were not kept at times they should have been and interventions focused on compliance rather than engagement.
Mr Dexter went on to say the department should have worked with the families better to identify barriers to schooling, to engage with the families, and to make sure kids were both attending school and learning once they were there.
In total, he identified 17 areas of improvement and said the department was working on a feasibility study to roll the systems in.
NT Health’s Richard Campion conceded that all three children should have had their cases upwardly referred to the CHO.
Cecelia Gore, also from the Department of Health, says moving forward it will be a “priority” for the department to make sure workers were familiar with the act.
What happens next?
On Monday, NT coroner Greg Cavanagh will hear the final submissions from lawyers and then take some time to consider the evidence before handing down his findings.
This will include recommendations for various government departments, as well as a summary of the issues highlighted throughout the inquest.