Inquest into the death of Kumanjayi Holmes

Conclusions

60. During the time that Kumanjayi was in the CEO's and Ms Teasdale's care she was loved and cared for, and her needs were provided for as best they could be in the circumstances of her disease. I commend Ms Teasdale on the care she provided to Kumanjayi.

61. TFHC conducted a Practice Review ("the Review") following her passing, and the Review formed part of the evidence in this inquest. It was unfortunate that there were significant challenges in funding Kumanj ayi' s care needs at sufficient levels and in a timely manner. At times there seemed to be a stalemate between the NDIS and TFHC as to which agency had responsibility to fund her care services. But Ms Martina O'Brien, Executive Director of Families Central Australian Region, explained that; "given the relative age of the scheme there remained uncertainty with respect to the division of responsibilities between the Department and the NDIS (which) was only resolved through proceedings at the AAT. Child Protection Practitioners are not experts in disability support and it is clear that, at times, these processes caused them some difficulty. "8

62. In spite of these difficulties, the involvement of TFHC and its Disability and Development Team ("DDT") established in 2020 contributed positively to the provision of services to Kumanja yi. I understand that the purpose of the DDT is to support children in care, like Kumanja yi, to ensure they receive appropriate supports and NDIS funding in accordance with their needs.

63. On behalf of the TFHC, Ms O'Brien explained that there is work occurring nationally to streamline communications between the NDIA and the various child protection agencies in each Australian jurisdiction. The DDT is currently working with the NDIA on a data sharing agreement which should Affidavit, Martina O'Brien, dated 11/10/2022 at [137-138]

allow the Department to have greater access to the details of the NDIS plans of children in out-of-home care.

64. In addition, I am told that the DDT now has a monthly 'operational meeting' with the NDIA where they are able to discuss issues relating to NDIS plans for children in out-of-home care. Ms O'Brien is hopeful that improved communication and a more collaborative working relationship between TFHC and the NDIA will reduce the need for appeals and the risk of NDIS plans running out of funding. These monthly meetings were commenced in response to the difficulties identified in the management of Kumanj ayi's care.

65. I make no recommendations in relation to this death.

Formal Findings

66. Pursuant to s34 of the Act, I make the following formal findings:

67. The identity of the deceased person was Damilia Kelly Holmes born 24 May 2006 at the Alice Springs Hospital, in Alice Springs in the Northern Territory of Australia.

68. The time and place of death was approximately 6.25pm on 31 October 2021 at the Alice Springs Hospital Palliative Care Ward, in Alice Springs in the Northern Territory of Australia.

111. The cause of death was complications of Batten disease (CLN3).

1v. Particulars required to register the death: a. The deceased was a female.

b. The deceased's name was Damilia Kelly Holmes.

c. The deceased was a child.

d. The deceased was of Aboriginal descent.

e. The death was reported to the Coroner.

f. A post-mortem examination was not carried out with the consent of the Coroner's office.

g. The cause of death was confirmed by Dr Marianne Tiemensma.

h. The deceased's mother was Roxanne Morton, and her father was Damsien Kelly-Holmes.

Dated this 31 day of March 2023.

ELISABETH ARMITAGE TERRITORY CORONER