Coroner's Court of Western Australia

Inquest into the Death of Child SK (Name Subject to Suppression Order)

Inquest into the Death of Child SK (Name Subject to Suppression Order)

Delivered on :8 April 2024

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations :Yes

Recommendation No. 1

In order to provide an appropriate level of community-based care to children and young people aged 17 years and under who have complex mental health conditions, that funding be provided to the Mental Health Commission as a matter of priority so that a permanent network of suitable models based on the Acute Care and Response Teams operating in the Perth metropolitan area can be established throughout the remainder of the state.

Recommendation No. 2

In order to provide a step-up/step-down facility for children and young people under the age of 16 years who have complex mental health conditions, that funding be provided to the Mental Health Commission as a matter of priority for a facility with an intensive day program.  This facility should be a hybrid model that applies the best features of the now closed Transition Unit and the current Touchstone program so as to provide an easily accessible service and an alternative to hospitalisation.

Orders/Rules : N/A

Suppression Order : Yes

Suppression of the deceased’s name from publication and any evidence likely to lead to the child’s identification.

The deceased is to be referred to as Child SK.

Summary : On 23 July 2020, Child SK died at Royal Perth Hospital from complications of a head injury. Two days earlier, she had intentionally stepped in front of an oncoming car on Albany Highway in Bentley. Child SK was 13 years old.

After receiving a submission from Child SK’s mother for an inquest and pursuant to section 22(2) of the Coroners Act 1996 (WA), the Court determined that a discretionary inquest into Child SK’s death was desirable in order to investigate the standard of the mental health care and treatment provided to Child SK, and the standard of community support services (including step-down facilities) after a hospital admission for children in Child SK’s age group with serious mental health issues.

In the last six months of her life, Child SK had attended the emergency department at Perth Children’s Hospital (PCH) on 11 occasions, with seven admissions to the mental health in-patient unit (Ward 5A). Six of these admissions to Ward 5A occurred in the six weeks between 4 June and 17 July 2020.  All these attendances related to self-harming incidents and/or expressed intentions to suicide.

By mid-June 2020, Child SK had been diagnosed with Emotionally Unstable Personality Disorder (EUPD), a disorder characterised by a tendency to act impulsively without consideration of the consequences and typified by chronic feelings of emptiness and suicidal behaviour. Treating psychiatrists had not encountered a more complex and challenging case of EUPD in a child or young person than Child SK’s.

Child SK’s treatment was complicated by the manner in which EUPD is managed which recognises that long hospital admissions are counterproductive. However, Child SK’s parents, despite their best endeavours, were unable to keep their daughter safe at home in the final months of her life due to her driven impulsivity to self-harm. As there was no step-up/step-down (SUSD) residential facility available for Child SK upon her discharge from PCH, she was discharged back into the care of her parents, notwithstanding her risk of self-harm and constant suicidal thoughts. Child SK had only been discharged from Ward 5A for five days when she deliberately stepped into the path of an incoming car, sustaining fatal injuries.

The Coroner was satisfied that Child SK’s death may have been prevented had an SUSD facility been available for her to reside in following her discharges from Ward 5A and before she was able to commence her participation in the community-based Touchstone program (an intensive treatment program designed to assist young people with EUPD). The earliest time Child SK could have participated in this program was 8 September 2020.

In addition to PCH, the Bentley Family Clinic (BFC) and the Department of Communities (the Department) were involved in the care of Child SK during the last six months of her life. The Coroner found that given the existing circumstances at the time, the treatment and care provided to Child SK by PCH (with one minor exception) and BFC was adequate. However, the Coroner was satisfied there were several missed opportunities with respect to the care provided by the Department.  

The Coroner welcomed the public statements from the state government committing itself to the implementation of the recommendations from the Chief Psychiatrist’s Targeted Review into the treatment provided to Child SK and the Ministerial Taskforce into the Public Mental Health Service for Infants, Children and Adolescents aged 0-18 years in WA. These two inquiries had ben finalised before the commencement of the inquest. In light of the comprehensive recommendations that had already been made by those inquiries, the Coroner only identified two further recommendations designed to enhance the treatment and care for children and young people with complex mental health conditions.

Catch Words : Adolescence Mental Health : Acute Care and Response : Step-Up/Step-Down Facilities : Recommendations : Suicide

Last updated: 19-Apr-2024

[ back to top ]