Demographics
14y, female
Coroner
Coroner Jenkin
Date of death
2022-04-20
Finding date
2025-12-17
Cause of death
ligature compression of the neck (hanging); suicide
AI-generated summary
A 14-year-old girl in state care (Child RK) died by suicide on 20 April 2022. She had complex presentations stemming from early childhood trauma, including attachment difficulties, emotional dysregulation, self-harm, suicidal ideation, substance misuse, and school disengagement. The coroner identified multiple missed opportunities: lack of complex case conferences despite escalating risk; failure to respond assertively to her friend's suicide in June 2021; inadequate follow-up after Crisis Connect assessments; failure to escalate her disengagement from school and counselling; and lack of care plan reviews before major placement changes. While the coroner found adequate general supervision by Department caseworkers, there was insufficient awareness of the cumulative negative impact of 'red flags' and limited integration between child protection and mental health services. The coroner found the death not preventable with certainty, but noted a more proactive, integrated response at key moments of deterioration might have improved support and reduced fatality risk. Key recommendations include implementing a stepped mental health care model, broadening escalation pathways, and providing additional training to caseworkers on identifying children at risk of self-harm and suicide.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
[2025] WACOR 53 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : MICHAEL ANDREW GLIDDON JENKIN, CORONER HEARD : 5-6 NOVEMBER 2025 DELIVERED : 17 DECEMBER 2025 FILE NO/S : CORC 991 of 2022 DECEASED : Child RK Cases: Briginshaw v Briginshaw(1938) 60 CLR 336 Legislation: Children and Community Services Act 2004 (WA) Coroners Act 1996 (WA) Counsel Appearing: Mr D McDonald appeared to assist the coroner.
Ms S Keighery and Ms T Richards (State Solicitor’s Office) appeared on behalf of the Department of Communities, the Child and Adolescent Health Service, and the Western Australia Police Force.
SUPPRESSION ORDER On the basis that it would be contrary to the public interest, I make the following order pursuant to section 49(1)(b) of the Coroners Act 1996 (WA): “There is to be no reporting or publication of the deceased’s name and/or any evidence likely to lead to the deceased’s identification, including but not limited to the names of any of the deceased’s siblings. The deceased is to be referred to as “Child RK”.
Order made by: MAG Jenkin, Coroner (05.11.25)
[2025] WACOR 53 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Michael Andrew Gliddon Jenkin, Coroner, having investigated the death of a female child referred to as Child RK with an inquest held at Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth, on 5 - 6 November 2025 find that death occurred on 20 April 2022 at 13 National Park Road, Swan View from ligature compression of the neck (hanging) in the following circumstances: Table of Contents
Child RK died in the early hours of 20 April 2022, at a therapeutic residential group home in Swan View from ligature compression of the neck. Child RK was 14-years of age.1,2,3,4,5,6,7
Child RK’s death was a “reportable death”, and as she was in the care of the Director General of the Department of Communities (the Department) at the relevant time she was a “person held in care”. In those circumstances an inquest is mandatory and I am required to comment on the quality of the supervision, treatment, and care that Child RK received whilst she was in that care.8,9,10
The documentary evidence at the inquest included a report into the police investigation of Child RK’s death, as well as various reports, including a case review prepared by an independent child and adolescent psychiatrist. The Brief comprised two volumes, and the following witnesses gave evidence at the inquest: a. Ms Andrea Willsher (Child RK’s Clinical psychologist);11 b. Ms Tracey Watters (Child RK’s Caseworker, Department);12 c. Dr Gosia Wojnarowska (Independent child and adolescent psychiatrist);13 d. Dr Vineet Padmanabhan (Director, Clinical Services, CAMHS);14,15 and e. Ms Amber Fabry (Chief practitioner, Department).16
When assessing the quality of the supervision, treatment and care Child RK received whilst she was in care, I have applied the standard of proof as set out in the High Court case of Briginshaw v Briginshaw (the Briginshaw case).17 1 Exhibit 1, Vol. 1, Tab 1, P100 - Report of Death Report (22.04.22) 2 Exhibit 1, Vol. 1, Tab 2, Report - Coronial Investigator D Sheahan (undated) 3 Exhibit 1, Vol. 1, Tab 4, Life Extinct Form (20.04.22) 4 Exhibit 1, Vol. 1, Tab 5, P92 - Identification of Deceased Person: Visual Means (20.04.22) 5 Exhibit 1, Vol. 1, Tab 7, Supplementary Post Mortem Report (24.05.22) 6 Exhibit 1, Vol. 1, Tab 7.1, Post Mortem Report (22.04.22) 7 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25) 8 Sections 3, 22(1)(a) and 25(3), Coroners Act 1996 (WA) 9 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25) 10 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25) 11 Exhibit 1, Vol. 1, Tabs 29 & 29.1 - 29.3, Reports - Ms A Willsher (various dates) & ts 05.11.25 (Willsher), pp7-39 12 Exhibit 1, Vol. 2, Tab 35, Statement, Ms T Watters (03.11.25) & ts 05.11.25 (Watters), pp64-100 13 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25) & ts 05.11.25 (Wojnarowska), pp40-64 14 CAMHS is the abbreviation for Child and Adolescent Mental Health Services 15 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25) & ts 06.11.25 (Padmanabhan), pp104-132 16 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25) & ts 06.11.25 (Fabry), pp132-172 17 (1938) 60 CLR 336, per Dixon J at pp361-362
The Briginshaw case is authority for the proposition that a consideration of the nature and gravity of the conduct is required when deciding whether a finding adverse in nature has been proven on the balance of probabilities.
I have also been mindful not to insert any hindsight bias into my assessment. Hindsight bias is the tendency, after an event, to assume the event is more predictable or foreseeable than it actually was at the time.18 In this case, the relevant event was Child RK’s death by suicide.
On the basis of the evidence of psychiatrists and psychologists in other inquests I have conducted, I am aware that suicide is a rare event and it is impossible to predict rare events with any certainty. I am also aware a person’s suicidality can fluctuate, often on relatively short timeframes, and that this is especially true for young people.
On the basis that Child RK was in care at the time of her death, I considered it was in the public interest to make a suppression order under section 49(1)(b) of the Coroners Act 1996 (WA) in relation to Child RK’s name and “any evidence likely to lead to the deceased’s identification”.19 The terms of my order appear on the cover page of this finding, and my order supersedes an order previously made by the Acting State Coroner on 13 June 2025.
Although Child RK’s first name was used by some counsel and witnesses during the inquest, the order I have made prevents her name from being published outside of that setting. Further, in order to protect Child RK’s identity I have used pseudonyms for her mother and her foster carers where it has been necessary to refer to them in this finding. No disrespect is intended to any person.
18 Dillon H and Hadley M, The Australasian Coroner’s Manual (2015), p10 19 Section 49(1)(b), Coroners Act 1996 (WA)
[2025] WACOR 53 CHILD RK Background20,21,22,23
Prior to the conclusion of the inquest, three of Child RK’s former foster carers gave moving statements about their relationship with her. These courageous statements gave a valuable insight into the person that Child RK was. It is very clear that despite her complex issues, and her often difficult and challenging behaviours Child RK was a loving child who was deeply loved by those who cared for her.
One of Child RK’s former foster carers (Ms B) gave a moving statement at the conclusion of the inquest and Ms B described Child RK in these terms: I was the one that had (Child RK) the longest. She came into my care just as she’s turning five. She was the most beautiful, precious, beautiful, loving girl, like, honestly. She had a lot of things that had happened to her prior to that, and she was very open about telling me about it, but they faded after a little while when she learned that she actually was in a family that loved her. She did display lots of anger towards her sibling…Her anger was never, ever at me. She loved me.
She trusted me. She was my everything.24
Although Child RK had one admission to Princess Margaret Hospital for treatment of “poor feeding” as an infant, she was not prescribed any medication, and no medical conditions were identified.
20 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25), pp1-2 21 Exhibit 1, Vol. 1, Tab 26, SAC1 Clinical Incident Investigation (15.06.22) 22 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p3-6 23 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25), pp4-6 24 ts 06.11.25 (Ms B), p176
[2025] WACOR 53 Medical history25,26,27,28,29,30,31,32,33,34
There is limited information about Child RK’s medical history in the Brief although asthma, and an allergy to seafood are listed in the “patient registration form” she completed when she attended St Andrews Medical Group in Midland (St Andrews) in early 2022.
From late-2019, Child RK’s mental health deteriorated and staff at the group homes she was placed in reported several incidents of self-harming behaviour, and suicidal threats and ideations.35
In July 2021, Child RK claimed she was pregnant and was planning an abortion. Although this information was communicated to the Department, there is no evidence that Child RK was pregnant. In her supplementary report, Ms Fabry notes that between 1 August 2021 and 20 April 2022: Communities supported Child RK to attend Perth Children’s Hospital (PCH) and engage with mental health supports in response to situational concerns impacting on her mental and/or psychological health.36
As I will point out, these “situational concerns” increased in frequency so from 4 December 2021 until the date of her death, Child RK had three presentations to hospital emergency departments relating to mental health crises, and risk-taking behaviours.37
On 7 February 2022, Child RK (accompanied by a care worker) saw Dr J Campbell at St Andrews. Child RK complained of difficulty with sleep over the past four days and she was prescribed melatonin.
25 Exhibit 1, Vol. 1, Tab 10, Report - Dr E Veerasamy, St Andrews Medical Group (06.10.25) 26 Exhibit 1, Vol. 1, Tab 10.1, Medical records - St Andrews Medical Group 27 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), pp4-5 28 Exhibit 1, Vol. 1, Tab 24, Department of Communities Records - Child RK (various dates) 29 Exhibit 1, Vol. 1, Tab 25, Report - Dr V Sharma (09.06.22) 30 Exhibit 1, Vol. 1, Tab 26, SAC1 Clinical Incident Investigation (15.06.22) 31 Exhibit 1, Vol. 1, Tabs 27 & 27.1, CAMHS records & Crisis Connect assessment 32 Exhibit 1, Vol. 1, Tab 28, Medical records - SJOG Midland Public Hospital 33 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25) 34 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25) 35 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p6 36 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), p4 37 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25), p5
Dr Campbell also wrote a referral for Child RK to be seen by “Midland Child Health” for “opinion and management”, and another for her to be assessed by a paediatrician for possible attention deficit hyperactivity disorder. In the referral, Dr Campbell said: I would appreciate you seeing (Child RK) who has been highlighted by Caseworker and also psychologist that there may be ADHD which she is keen to get assessed for. She has had anger issues and bereavement which is why she is seeing a psychologist.38,39,40,41
On 4 April 2022, Child RK (accompanied by a care worker) was seen by Dr E Veerasamy at St Andrews. Although Child RK was “only communicating with a few words of answer”, she said she was having sleep issues as a result of an unspecified “stressful situation”. Child RK said the melatonin she was prescribed had helped, and that she had previously been prescribed diazepam with good effect.42,43
In his report, Dr Veerasamy said he was told Child RK was “waiting to see a psychiatrist for further assessment and treatment”, and that he confirmed the earlier referral made by Dr Campbell. Dr Veerasamy also noted that: “With caution, I prescribed diazepam, 2 tablets of 5 mg to be used on consecutive nights with support staff supervising with the medication”.44,45
Although Child RK was due to see Dr Veerasamy again on 19 April 2022, on the way to the appointment, Child RK asked her care worker to stop the car before she got out saying she would not be attending the appointment. Dr Veerasamy spoke briefly with the care worker and declined a request to prescribe additional diazepam without reviewing Child RK. Dr Veerasamy offered a “phone consult” but this was declined by the care worker.46,47,48,49 38 Exhibit 1, Vol. 1, Tab 10, Report - Dr E Veerasamy, St Andrews Medical Group (06.10.25) 39 Exhibit 1, Vol. 1, Tab 10.1, Medical records - St Andrews Medical Group (07.02.22) 40 Exhibit 1, Vol. 1, Tab 10.1, Letter - Dr J Campbell to Midland Child Health (07.02.22) 41 Exhibit 1, Vol. 1, Tab 10.1, Letter - Dr J Campbell to Dr M Jehangir (07.02.22) 42 Exhibit 1, Vol. 1, Tab 10.1, Medical records - St Andrews Medical Group (04.04.22) 43 Exhibit 1, Vol. 1, Tab 10, Report - Dr E Veerasamy, St Andrews Medical Group (06.10.25) 44 Exhibit 1, Vol. 1, Tab 10.1, Medical records - St Andrews Medical Group (04.04.22) 45 Exhibit 1, Vol. 1, Tab 10, Report - Dr E Veerasamy, St Andrews Medical Group (06.10.25) 46 Exhibit 1, Vol. 1, Tab 10.1, Medical records - St Andrews Medical Group (19.04.22) 47 Exhibit 1, Vol. 1, Tab 10, Report - Dr E Veerasamy, St Andrews Medical Group (06.10.25) 48 Exhibit 1, Vol. 1, Tab, 11, Reports and Occurrences (19.04.22) 49 Exhibit 1, Vol. 1, Tab, 12, Shift Report - Mr G Carter, Senior Residential Care Worker (19.04.22))
[2025] WACOR 53 Mental health issues50,51,52,53,54,55,56,57,58,59,60,61
Although Child RK was never diagnosed with any mental health issues, it is clear that she had numerous complex issues as a result of her exposure to early childhood trauma. Dr Padmanabhan62 is an experienced child and adolescent psychiatrist, and he reviewed Child RK’s case and provided a report to the Court. In his report, Dr Padmanabhan made the following comments about the complexity of Child RK’s presentation: Child RK’s clinical presentation was complex. In a clinical context, complexity is measured not by a diagnosis alone, but by the interaction of multiple factors that influence a child’s functioning, risk, and response to intervention. A child may have a single diagnosis but still present as highly complex if they display emotional and behavioural escalations, experience attachment disruptions or instability in care environment. In Child RK’s case, all those factors appear to have been present. There was also a history of substance misuse and absconding from the residential care home.63,64
As to Child RK’s possible diagnoses, Dr Padmanabhan stated: Given Child RK’s complex developmental history, attachment disruptions, and behavioural profile, an appropriate diagnosis would need to consider the impact of early childhood trauma. In my opinion, possible diagnostic considerations include Complex Post-Traumatic Stress Disorder (PTSD). On reviewing the information available to me as part of the brief, Child RK’s presentation also aligns with Emotionally Unstable Personality Disorder traits (borderline type), though a diagnosis of personality disorder should be made with caution in a child of 14 years… 50 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25) 51 Exhibit 1, Vol. 1, Tab 24, Department of Communities Records - Child RK (various dates) 52 Exhibit 1, Vol. 1, Tab 25, Report - Dr V Sharma (09.06.22) 53 Exhibit 1, Vol. 1, Tab 26, SAC1 Clinical Incident Investigation (15.06.22) 54 Exhibit 1, Vol. 1, Tabs 27 & 27.1, CAMHS records & Crisis Connect assessment 55 Exhibit 1, Vol. 1, Tab 28, Medical records - SJOG Midland Public Hospital 56 Exhibit 1, Vol. 1, Tabs 29 & 29.1 - 29.3, Reports - Ms A Willsher (02.03.22, 07.09.20. 03.02.20 & 07.06.19) 57 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25) 58 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25) 59 Exhibit 1, Vol. 2, Tab 36, Transitional Home Interim Safety Plan (18.08.21) 60 Exhibit 1, Vol. 2, Tab 37, Safety Plan (06.09.21) 61 Exhibit 1, Vol. 2, Tab 38, Trauma Profile (04.11.21) 62 Dr Padmanabhan is the Director, Clinical Services at Child and Adolescent Mental Health Services 63 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25), p4, para 37 64 At the inquest, Dr Padmanabhan rated Child RK’s complexity as between 8-10 out of 10: ts 06.11.25 (Padmanabhan), p109
[2025] WACOR 53 Child RK’s early childhood experiences may have impacted her emotional and psychological wellbeing. From the information available she could meet the criteria for Complex PTSD as defined by the ICD-11 (11th revision of the International Classification of Diseases), which includes the core symptoms of PTSD such as intrusive memories, avoidance of reminders, and a persistent sense of threat, as well as additional difficulties with emotional regulation, a negative selfimage, and challenges in forming safe and trusting relationships.65,66
At the Court’s request, Dr Wojnarowska (an experienced child and adolescent psychiatrist) reviewed Child RK’s case and provided a report to the Court. At the inquest, Dr Wojnarowska said that Child RK’s presentation was “the most severe” of numerous children in care cases she had reviewed,67 and that: (Child RK) was a child of complex needs that were stemming from her developmental history, attachment history, trauma that she was exposed to, violence, and then multiple placements that she has experienced in her life. So as such, during her formative years, she started to display behaviours that were highly suggestive of behavioural and emotional disturbance of a person who has developed complex post-traumatic stress disorder, on a background of attachment difficulties and other adverse life events.68
In her report Dr Wojnarowska also expressed the following opinion about Child RK’s likely diagnoses: It is likely that (Child RK’s) difficulties reflect the complex interaction of exposure to a highly stressful environment; experience of trauma; maternal substance abuse; family domestic violence, maternal mental illness and inconsistent and disrupted schooling. Exposure to these negative life events at an early age can contribute to delays in brain development and maturation (particularly in neuro networks important for development of executive functioning skills) and disrupt stress hormones… 65 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25), paras 43-44 66 ts 06.11.25 (Padmanabhan, pp108-109 67 ts 05.11.25 (Wojnarowska), p42 68 ts 05.11.25 (Wojnarowska), p41
[2025] WACOR 53 Trauma may also engender feelings of victimization, loss of control, despair and hopelessness and beliefs that the world is unsafe and life unfair. Early traumatic experiences can contribute to further changes in the subsequent development of brain structures and brain functioning; give rise to intense and chronic emotional and behavioural dysregulation; result in depression and anxiety and difficulty with selfregulation. (Child RK) presented with numerous concerning behaviours. This likely represented the response to the extreme maltreatment and trauma she had been subjected to and as such a diagnosis of complex Post-Traumatic Stress Disorder (PTSD) is appropriate.69 (Original emphasis)
By definition, all children in care have complex issues, but on the basis of the expert opinions of Dr Wojnarowska and Dr Padmanabhan, I have concluded that Child RK’s case was particularly complex.
I am aware that caseworkers70 are often social workers and some may be psychologists. I also accept that child protection work is difficult, and that caseworkers approach their responsibilities diligently and with the child’s best interests at the forefront of their thinking.
Nevertheless, after carefully considering the available evidence (including the evidence of Ms Watters and Ms Fabry at the inquest), I have concluded that the Department failed to appreciate the cumulative impact on Child RK’s mental health of a number of “red flags” which I will refer to later in this finding.71 Issues relating to psychological counselling
Child RK attended numerous counselling sessions with Ms Willsher (a clinical psychologist) over the period 2018 to 2021, and Ms Willsher said this about Child RK’s initial presentation: “there were some behaviour issues at home. There had been an escalation, and the trigger had been an unexpected interaction with her biological mother at the swimming pools, and that…was the trigger of an escalation in behaviour issues”.72 69 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p13 70 I have used this term to refer to the workers now known as “Child Safety Practitioners” by the Department 71 ts 05.11.25 (Watters), pp64-100 & ts 06.11.25 (Fabry), pp132-172 72 ts 05.11.25 (Willsher), p9
Ms Willsher gave evidence at the inquest, and copies of four of the reports she provided the Department appear in the Brief.73 In the earliest of these reports dated 7 June 2019 (First Report),74 Ms Willsher set out her formulation of Child RK’s presentation and provided a clear framework for understanding Child RK’s behaviour in the context of early childhood trauma, including neglect and abandonment.75
At the end of the First Report, Ms Willsher made several recommendations, including that Child RK continue her counselling sessions, and that she have regular contact with her siblings, and regular supervised contact with a former foster carer. In terms of managing Child RK’s challenging behaviours, Ms Willsher recommended: Reduction in authoritarian punitive behaviour management approaches to manage difficult behaviours: i.e. significantly reduce use of punishments such as time out, taking away special objects or privileges, and ignoring…(and)…Use of prompting and positive reinforcement of desired behaviours to improve cooperation and engagement in desire behaviours, alongside empathic responding and redirection to desired behaviours.76
In the section of the First Report dealing with the sessions Child RK had attended between 9 May 2019 to 4 June 2019, Ms Willsher noted: “(Child RK) reported feeling upset and appeared downcast when describing living in a group home. She stated she wished to be placed in a foster home with a carer who had no other children.77
As I will explain, it is significant that in the First Report Ms Willsher made the following recommendation about Child RK’s placement: Placement in a foster home with a carer trained in cooperative behaviour management and emotional coaching - i.e. responding to aggressive behaviours utilising an empathic, compassionate and cooperate approach with consistent boundary setting.78 73 Exhibit 1, Vol. 1, Tabs 29 & 29.1 - 29.3, Reports - Ms A Willsher (02.03.22, 07.09.20. 03.02.20 & 07.06.19) 74 The First Report summarises the 20 counselling sessions that Child RK attended from 7 February 2018 to 4 June 2019 75 Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19), pp8-9 & ts 05.11.25 (Willsher), pp15-16 76 Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19), p9 77 Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19), p7 78 Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19), p9
By the time of the First Report (i.e.: 7 June 2019), Child RK had been relocated to a group home. In any case when read in context it is patently obvious that by using the phrase “foster home” in the recommendation I have quoted, Ms Willsher was referring to a placement with a foster carer. Any other interpretation of that recommendation is illogical, and clearly wrong.79
I will briefly summarise aspects of Child RK’s placement history later in this finding. For now, it is enough to observe that on the basis of the evidence before me, insufficient attention was given to Child RK’s strong desire to return to a foster care arrangement with a foster carer.
I accept that Child RK’s previous foster care placements had broken down due to her challenging behaviours. Nevertheless, as Ms Willsher outlined in the First Report, the breakdown of these foster care placements added to Child RK’s feelings of abandonment and feelings of self-worth.80
I note that Ms Willsher identified some issues with the parenting style adopted by one of Child RK’s foster carers (Ms B). I also note that Child RK’s subsequent foster carer (Ms C) was understandably struggling to cope with Child RK’s behaviours while working full-time and dealing with the illness of an elderly a family member.81
I wish to make it clear that I make no criticism of any of Child RK’s foster carers. Those who are willing undertake foster carer roles, especially for complex and challenging children, are to be warmly congratulated. Being a foster carer is a voluntary undertaking for which there is minimal training and variable levels of support.82
Child RK’s foster carers provided her with loving and safe home environments for as long as they were able to do so safely. Child RK’s desire to return to a placement with a foster carer was unrealistic due to her behaviour.83 79 Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19), p9 80 Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19), pp7-8 81 Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19) 82 ts 06.11.25 (Fabry), pp135-138 83 See also: ts 06.11.25 (Ms B), pp176180-176; ts 06.11.25 (Ms C), pp173-176 & ts 06.11.25 (Ms D), pp180-184
Further, Child RK’s strong attachment to Ms B (who she typically referred to as “Mum”) meant that subsequent foster care placements tended to be viewed by Child RK as temporary, because she assumed (incorrectly) that she would be returning to live with Ms B.84
In my view, these placement difficulties (including the reasons why foster carer placements were deemed unsuitable) needed to be addressed with Child RK in a collaborative way.
It is therefore unfortunate that Ms Willsher’s offer of a case conference in her email dated 17 March 2021 (the Email) was not embraced by the Department. This is especially so given the fact that Ms Willsher had established a good rapport with Child RK over several years, and this was set to continue. The Email (which came at the end of series of emails between Ms Willsher and the Department about Child RK’s management) states: (Child RK) has 5 sessions left under the current referral. Her last session attended was 3/02/21. Let me know if you wish to have case conference regarding her progress and end of placement contract and plans for where she will be placed or let me know what has been decided so I can work with (Child RK) around this. She has hoped for a long time that she would be placed back into foster care.
This uncertainty, in combination with past experiences of being removed from placements with mother - figures (Ms B) and (Ms C), could be the cause of the escalation of her aggressive behaviours.85,86 (Emphasis added)
Ms Fabry’s response was: So, it’s important that we correct the record, and we will do so. So just looking through the file yesterday, I found when one of those reports was received, there was immediately a consultation with our internal district psychologists, and some action was taken. So, I’m sorry we didn’t prepare. We weren’t aware that that was going to be the subject of this inquest, but we will prepare to let you know more specifically the interactions that occurred. We have lots of records, and I would like to address that, but whether now is exactly the right time.88
In relation to the Email, the Department’s position is that although an email from Ms Fiorina to Ms Willsher on 11 March 2021 exists, it has no evidence that the Email was ever received by the Department. In an email sent to Mr McDonald on 5 December 2025, Ms Keighery (counsel for the Department) advised that her instructions were as follows: The position is that it (the Email) does not exist in any database including on (Ms Fiorina’s) email. Ms Fiorina does not recall ever having seen (the Email) or any suggestion from (Ms Willsher) for a case conference. (Ms Fiorina) would have saved it or actioned it if it was in her email box. Communities cannot say why no one received (the Email) or why alternatively (the Email) was not sent. There are numerous reasons but they would be not based on facts that we are aware of [eg technical issues with (Ms Willsher’s) email server, error in not sending an email, error in servers etc]. Whatever the reason it was not received by Communities the relevant issue is that (Communities) could not respond to something they never were notified of. (Communities) could not have organised a case conference with (Ms Willsher) as they did not receive that information.89
In a statement dated 16 December 2025, Ms Fabry confirmed that the Department’s Central Review Team had conducted a search of “child protection records” for the Email, and: The Department cannot locate in the electronic file records document Exhibit 1 Tab 30.1 page 41 (i.e.: the Email). The Department's records with InFocus Counselling are summarised in Attachment A. The 88 ts 06.11.25 (Fabry), p145 89 Email - Ms S Keighery to Mr D McDonald (05.12.25)
[2025] WACOR 53 Central Review Team has contacted Ms Fiorina who was Child RK's case manager in March 2021. Ms Fiorina has informed the Central Review Team she does not have (the Email) in her email or archived records. Ms Fiorina has informed the Central Review Team she does not recall ever seeing (the Email). Ms Fiorina has informed the Central Review Team she does not recall Ms Willsher suggesting a "case conference".90
On the basis of the evidence before me, I am satisfied that Ms Willsher sent the Email to the Department. However, I note (without comment) that the Department’s contention is that it has no evidence that the Email was received. Further, Child RK’s caseworker at the relevant time does not recall seeing the Email, nor does the caseworker recall Ms Willsher suggesting a case conference. In my view this choice of language is significant, as the caseworker does not say that a case conference was never suggested.
In any case, at the inquest, Ms Watters (who was Child RK’s caseworker at the relevant time) was asked whether, with the benefit of hindsight, it would have been appropriate for the Department to have had a case conference with Ms Willsher about Child RK’s placement issues.
Ms Watters initially seemed sceptical of the utility of such a meeting, and the following exchange took place: Mr McDonald (Counsel Assisting): And I suppose as (Child RK’s) long-term case manager, would that have been a meeting that would have been of assistance to you and the Department?
Ms Watters: No, I don’t think so.91
[2025] WACOR 53 ground with her every day, I didn’t see it that way. So, if that was brought to my attention, then potentially it could have.92
In her evidence at the inquest, Ms Fabry pointed to a series of emails between the Department and Ms Willsher in the relevant period as evidence of consultation, although Ms Fabry properly conceded that “The feedback loop wasn’t as strong as it could be”.93
The emails between the Department and Ms Willsher do not deal with planning for future placements, and a case conference with Ms Willsher never occurred.94 Even if I accept the Department’s assertion that it has no record of receiving the Email, Ms Willsher’s reports make it clear that Child RK was unhappy with group home placements, and that the breakdown of her foster care placements was having a significant and negative impact on Child RK’s behaviour.
In that context, the following observations Ms Willsher made at the inquest (with which I agree) are clearly relevant: I think as the treating psychologist, there needs to be a way to integrate us more into the care that’s happening with the child, because it very much feels sometimes that we’re doing - well, for me, that I’m doing this work over here, and trying really hard, but we need it to be communicated back so that…things that can be applied, or things that I can know that would help me, that are in my work. It can feel quite isolating, being on the outside, and from there, I have had other children that I work with, and that is a difficulty that is ongoing, and I think that case conferences should be a part of the referral process. We should do so many sessions and then have a case conference with the case manager…and/or the psychologist, so that we have a plan together of where to go.95,96 (Emphasis added) 92 ts 05.11.25 (Watters), p73 & see also ts 05.11.25 (Watters), pp95-96 93 ts 06.11.25 (Fabry), pp145-148 & 156-157 94 ts 06.11.25 (Fabry), pp156-158 95 ts 05.11.25 (Willsher), pp25-26 & see also: ts 05.11.25 (Willsher), pp26-27 96 At the inquest Ms Watters said that she did have phone conversations with Ms Willsher (the details of which Ms Watters could not recall). However, Ms Watters confirmed that she would not have discussed the Department’s foster care plans for Child RK with Ms Watters, see: ts 05.11.25 (Watters), pp77-80
[2025] WACOR 53 THE DEPARTMENT’S INVOLVEMENT WITH CHILD RK Overview97,98,99,100
Between 2008 and 2012, Child RK was the subject of several child safety investigations relating to allegations of abuse and neglect. On 3 August 2012, the Department took Child RK and her two younger siblings into care on the grounds of substantiated neglect.101
This followed concerns which had been expressed about the mental state of Child RK’s mother (Ms A), who was reportedly paranoid and delusional. Ms A had for example expressed concerns that her house “had been gassed”, that “people were living in her roof”, “that food and water in the house was being poisoned”, and that her children had been sexually abused.102
Child RK remained in the care of the Department from 3 August 2012 until her death. During that time, Child RK was managed in variety of general foster care, group home, and therapeutic residential care placements, and as Ms Fabry explained in her first report: During her life, Child RK had 70 care arrangements, which included 22 primary care arrangements, and 48 short break care arrangements.
From 1 February 2013 at the age of five, to 13 August 2018 at the age of 10, Child RK was in the care of a Communities’ community foster carer103 (Ms B) with two of her siblings.104
These included: aggression and threats, sexualised behaviours, frequent absconding, ongoing truancy (and eventually school refusal), polysubstance use (including methylamphetamine), episodes of selfharm, and occasional expressions of suicidal ideation.105 97 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25) 98 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25) & ts 06.11.25 (Fabry), pp132-172 99 Exhibit 1, Vol. 1, Tab 24, Department of Communities Records - Child RK (various dates) 100 Exhibit 1, Vol. 1, Tab 9, Department of Communities - Response to Child Death Notification 101 ts 06.11.25 (Fabry), pp132-133 102 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25), p4 103 This placement with Ms B was Child RK’s most enduring placement 104 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25), p4 105 Exhibit 1, Vol. 2, Tab 38, Trauma Profile (04.11.21)
As noted earlier, the primarily reason seems to be that Child RK incorrectly assumed that the breakdown of her placement with Ms B would only be temporary.
Although the Department was able to secure Child RK one further placement with a general foster carer (Ms C), this placement which lasted from 16 August 2018 to 6 May 2019, also broke down because of Child RK’s challenging behaviours. Thereafter, Child RK was managed in either group homes or therapeutic residential homes, settings which she clearly did not like.
In her report Ms Fabry noted that in 2021, Child RK absconded from her group home placements on 96 occasions, and in 2022 she had absconded on 33 occasions. During these times, Child RK was unaccounted for periods ranging from a few hours to five days. Whilst I accept the Department has limited options to prevent a child from leaving their foster care placements, these absences are concerning.
In Child RK’s case, it appears that during at least some of these periods of absence from care, she may have been engaging in sexual activity with older males in return for methylamphetamine, and/or risky behaviour involving polysubstance use.106
In my view, it is significant that Child RK’s periods of absence in 2021 and 2022 occurred while she was placed in group homes or therapeutic residential care. Obviously by 2021, Child RK was older and therefore more physically capable of absconding. Nevertheless, these repeated absences underscored the need to address Child RK’s desire to return to general foster care placements in a collaborative way.107 106 Exhibit 1, Vol. 2, Tab 38, Trauma Profile (04.11.21) 107 See: Exhibit 1, Vol. 1, Tab 29.3, Report - Ms A Willsher (07.06.19), p7
Significantly in Child RK’s case, those vacancies included two caseworker positions, an education officer and a clinical psychologist.
At around the same time (March 2020 - September 2021) 14 - 16 staff were on leave, including Child RK’s caseworker.108
These absences had the effect of “impacting on the continuity of case managers on Care Teams”, and during the same period eight of 12 positions on the “District Leadership Team” were “acting opportunities with limited experience in management roles”. As if to add insult to injury, the staffing issues facing the District Office were compounded by COVID-19 restrictions and “some service delivery was impacted.109 Overview of Child RK’s placements110,111,112,113,114,115,116,117,118,119,120,121,122,123,124
While Child RK was in care (3 August 2012 to 20 April 2022), she was managed in general foster care, group home, and therapeutic residential care placements. As noted, although Child RK did have one long-term foster care placement (i.e.: with Ms B), Child RK’s extremely challenging behaviours led to the breakdown of this placement. These behaviours included: aggression and threats, sexualised behaviours, frequent absconding, school refusal, polysubstance use, episodes of selfharm, and occasional expressions of suicidal ideation.
108 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), p2 109 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), p2 110 Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25) & ts 06.11.25 (Fabry), pp132-172 111 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25) 112 Exhibit 1, Vol. 1, Tab 24, Department of Communities Records - Child RK (various dates) 113 Exhibit 1, Vol. 1, Tab 26, SAC1 Clinical Incident Investigation (15.06.22) 114 Exhibit 1, Vol. 1, Tabs 27 & 27.1, CAMHS records & Crisis Connect assessment 115 Exhibit 1, Vol. 1, Tab 28, Medical records - SJOG Midland Public Hospital 116 Exhibit 1, Vol. 1, Tabs 29 & 29.1 - 29.3, Reports - Ms A Willsher (02.03.22, 07.09.20. 03.02.20 & 07.06.19) 117 Exhibit 1, Vol. 1, Tab 30, Counselling Records - Sunset Psychology & ts 05.11.25 (Willsher), pp7-39 118 Exhibit 1, Vol. 1, Tab 30.1, Counselling Records - InFocus Psychology 119 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25) & ts 06.11.25 (Wojnarowska), pp40-64 120 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25) & ts 06.11.25 (Padmanabhan), pp104-132 121 Exhibit 1, Vol. 2, Tab 35, Statement, Ms T Watters (03.11.25) & ts 05.11.25 (Watters), pp64-100 122 Exhibit 1, Vol. 2, Tab 36, Transitional Home Interim Safety Plan (18.08.21) 123 Exhibit 1, Vol. 2, Tab 37, Safety Plan (06.09.21) 124 Exhibit 1, Vol. 2, Tab 38, Trauma Profile (04.11.21)
My overall assessment is that the care and supervision Child RK received during these placements was adequate. In particular, it is clear that Child RK’s various foster carers did their best to provide her with loving and safe home environments.
b. 11 February 2015: the Department initially facilitated supervised contact visits between Child RK and her mother (Ms A), but this contact was permanently suspended on 11 February 2015 on the basis it was not in Child RK’s best interests. The Department’s decision was clearly correct and Ms A’s conduct during these contact visits underscored the reasons why Child RK was taken into care in the first place. Although Child RK later resumed contact with Ms A, there was little the Department could do.126 c. 7 February 2018: Child RK was verbally and physically aggressive and threatening towards Ms B, and her siblings and foster-siblings, and she began refusing to attend school. As a result, the Department arranged for Child RK to recommence psychological counselling.
d. 13 August 2018: despite regular respite placements and her ongoing counselling, Child RK’s behaviour did not improve and Ms B reluctantly advised the Department that she was no longer able to manage Child RK’s extremely challenging behaviours and the placement would have to end.
125 Ms Fabry said that Child RK’s number of placements was on the high end of the scale: ts 06.11.25 (Fabry), p134 126 ts 05.11.25 (Watters), pp81-82
[2025] WACOR 53 d. 13 August 2018: (continued) Ms B’s decision is completely understandable, especially because at the relevant time, Ms B was also caring for two of Child RK’s siblings, as well as her own biological children. As a result of the breakdown of this care placement, the Department created a transition plan to relocate Child RK to a new foster carer.
e. 16 August 2018 - 6 May 2019: Child RK refused to comply with the foster care placement that had been arranged by the Department and threatened to make allegations of abuse. As a result, Child RK was placed in an emergency foster care placement, before she was placed with a foster carer (Ms C).
Child RK remained in Ms C’s care until 6 May 2019, when the placement broke down because of her (Child RK’s) challenging behaviour.
f. 6 - 21 May 2021: on 6 May 2019, Child RK was placed in a residential group home in Maddington where she reportedly displayed aggressive, and sexualised behaviour. On 20 May 2019, Child RK was moved to a group home in Meadow Springs, where she made threats to stab carers and other children.
On 21 May 2019, Child RK was transferred to a group home in Halls Head where she remained until 18 August 2021.
g. 7 June 2019: Ms Willsher provided a report to the Department, in which she noted the profound impact on Child RK of removal from foster carers, and placement in a group home. Ms Willsher recommended (amongst other things) that Child RK be placed in a foster home with a carer trained in cooperative behaviour management and emotional coaching.
In passing I note that at the inquest, Dr Wojnarowska said this about the impact on Child RK (a child who may have had complex PTSD) of numerous care placements: Well, it does deprive them from any sense of safety and security in the world, and cuts in a dramatic way any attachments that they manage to form with their carers and notwithstanding the feelings of rejection and possibly guilt and self-blame.127 h. August - November 2020: from August 2020, Child RK began leaving school grounds without permission, and by November 2020, she refused to attend school at all. There is no evidence Child RK attended school again prior to her death.
127 ts 05.11.25 (Wojnarowska), p42
[2025] WACOR 53 i. 17 March 2021: Ms Willsher emailed the Department and expressed concerns about Child RK’s ongoing absence from school and her desire to return to foster care. Ms Willsher noted the impact of Child RK’s previous removals from foster care and suggested a case conference to discuss Child RK’s placement arrangements. The Department says it can find no evidence that this email was ever received.128,129 j. June - July 2021: Child RK’s close friend (Child K) reportedly took her life in June 2021. Child RK was provided with a single counselling session on 30 June 2021. Unfortunately, as Ms Willsher was on leave, Child RK had to meet with a clinical psychologist she had not previously seen.130,131 k. 18 - 24 August 2021: on 18 August 2021, Child RK was placed in a therapeutic care home until 24 August 2021. Child RK was moved to another therapeutic care home (National Park House) where she stayed until her death.
l. 4 December 2021: was taken to St John of God Midland Public Hospital by police after she self-harmed with a piece of broken glass and threatened to hang herself. During a video-call assessment with the Crisis Connect service, Child RK disclosed suicidal ideation and an 18-month history of self-harming behaviour, and she also said she had visited Child K’s grave that day. Child RK was discharged home and she refused to speak with a Crisis Connect worker when they called the following day.
m. 30 December 2021: Child RK was taken to Perth Children’s Hospital (PCH) by ambulance after hitting herself in the head with a brick and threatening to drown herself in a pool. Child RK was seen by a psychiatrist, who concluded she was not at acute psychiatric risk and discharged her home.
A scheduled follow up call was made by Crisis Connect the following day, and although Child RK was asleep, a care worker reported she was settled.
n. 1 - 3 January 2022: Child RK was taken to PCH by ambulance in a distressed state. She expressed suicidal ideation and was seen by a psychiatric registrar who noted chronic suicidal ideation and attempts at strangulation.
Child RK was assessed as not being at acute psychiatric risk and instead to be experiencing an acute stress reaction. Child RK was discharged home with a referral to Swan Community CAMHS for assessment and treatment.
128 See also: ts 05.11.25 (Watters), pp96-97 129 Email - Ms S Keighery to Mr D McDonald (05.12.25) 130 ts 05.11.25 (Willsher), p39 131 See also: ts 06.11.25 (Padmanabhan), pp111-112 on the importance of more comprehensive follow up at this time
[2025] WACOR 53 n. 1 - 3 January 2022: (continued) A scheduled follow up was made by Crisis Connect on 2 January 2022, but Child RK was asleep. The following day, Child RK refused to speak with the Crisis Connect worker.
o. 4 January 2022: the offer of an assessment with a Community CAMHS clinician (Choice appointment) on 18 January 2022 was declined to accommodate Child RK’s preference for a female clinician. A morning appointment on 21 January 2022 was also declined, and an afternoon appointment on 25 January 2022 was booked instead.
p. 25 January 2022: Child RK was seen by a clinical nurse specialist at Swan Community CAMHS, who conducted a risk assessment and safety plan. Child RK was offered a Choice Plus appointment for a comprehensive evaluation by a psychiatrist, and a review and neurodevelopmental assessment by a paediatrician was also suggested. Although a Choice Plus appointment was scheduled for 8 March 2022, this appointment was rescheduled on several occasions. The appointment was eventually to have been held on 20 April 2022, which ironically was the date of Child RK’s death.
Missed opportunities132,133,134
Since Child RK’s death, the Department has made changes to improve its service delivery, and its coordination with other agencies and services.
I will refer to some of these developments later in this finding, and I have made recommendations touching on these issues.
132 ts 06.11.25 (Fabry), pp132-172 & see also: Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25) 133 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25) , pp17-19 & ts 05.11.25 (Wojnarowska), pp48-50 134 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25) & ts 06.11.25 (Padmanabhan), pp104-132
In her report and at the inquest, Dr Wojnarowska identified what she considered were a number of missed opportunities in Child RK’s care and treatment.135
At the inquest, Ms Fabry agreed that with the benefit of hindsight, the Department could have provided Child RK with “more assertive wrap around support” in the period July to December 2021, and that this “could have made a difference”.136 Ms Fabry also explained the importance of conducting care plan reviews and why these reviews ought to have been conducted prior to each major change in Child RK’s foster care or group home placements.137
At the inquest, Dr Padmanabhan identified the cumulative impact on Child RK’s mental health of a number of “red flag” events. These events included: Child RK’s disengagement from school and from her longterm psychological counselling sessions, and the death by suicide of Child RK’s close friend (Child K).138
To this list I would also add Child RK’s persistently stated desire to return to a foster care placement with a carer rather than a group home.
Whilst this desire was unrealistic, at least in 2021, because of Child RK’s challenging behaviours, it was clearly something that was important to her for the reasons I have earlier explained.
135 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), pp17-19 & ts 05.11.25 (Wojnarowska), pp48-50 136 ts 06.11.25 (Fabry), p148 & see also: ts 06.11.25 (Fabry), p157 137 ts 06.11.25 (Fabry), pp143-145 & see also: ts 06.11.25 (Fabry), pp151-155 & 170 138 ts 06.11.25 (Padmanabhan), pp112, 118-119 & 131-132
[2025] WACOR 53 These occasions include (but are not limited to): the conference suggested by Ms Willsher in her email on 17 March 2021; the death of Child RK’s friend (Child K) by suicide in July 2021; and the period “during RK’s escalating risk profile as documented in ED presentations in late 2021”.139 I also agree with the following observation Dr Wojnarowska made in her report: At these junctures, a coordinated interagency response could have enabled a shared understanding of RK’s risk profile, clarified roles and responsibilities, ensured consistent messaging across services, and facilitated the implementation of assertive outreach or alternative support pathways.140 b. Failure to escalate disengagement from schooling and counselling: As I have noted, from around August 2020, Child RK had started truanting from school, and she was not in full time schooling of any kind after November 2020.
Further, Child RK had effectively disengaged from her counselling sessions with Ms Willsher by March 2021.
In my view it is significant that on 22 April 2021, it was Halls Head College that advised the Department that Child RK could be referred to the School of Special Educational Needs. This was six months after Child RK had completely disengaged from school, and this option should have been recommended earlier by the Department’s own education officer.141 At the inquest, Dr Padmanabhan described these disengagements by Child RK as serious “red flags”.142 In my view the significance of these issues was not properly appreciated by the Department at the relevant time, and there was insufficient attention to either of these disengagements.143 c. Lack of follow up after incident reports in residential care: On 3 - 7 March 2021, Child RK was the subject of a number of reports relating to incidents of physical aggression towards carers, and as Dr Wojnarowska pointed out in her report: “These behavioural incidents were clear indicators of distress and escalating risk. There is no evidence that they led to further clinical review, adjustment of placement or therapeutic supports, or escalation within child protection or mental health services”.144 139 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p17, paras 108-109 140 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p18, para 110 141 See: Exhibit 1, Vol. 1, Tab 23, Report - Ms A Fabry (01.10.25), p19 142 See for example: ts 06.11.25 (Padmanabhan), p111 143 On the importance of Child RK regularly attending school, see also: ts 05.11.25 (Wojnarowska), pp42-44 144 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p18, para 114
[2025] WACOR 53 d. Lack of assertive response following suicide of Child RK’s close friend: The death by suicide of Child RK’s close friend (Child K) in June 2021, was a major traumatic event in Child RK’s life. Child RK made several trips to Child K’s grave and she had photographs of Child K’s gravesite on her mobile phone.145 On 30 June 2021, Child RK attended a single counselling session with a clinical psychologist other than Ms Willsher (who was then on leave).146 This appears to be the only formal psychological support Child RK was provided with in relation to Child K’s death.
I therefore strongly agree with Dr Wojnarowska’s observations that: The suicide of RK’s close friend represented a major traumatic event that significantly compounded her existing vulnerabilities. Despite the known impact of peer suicide on at-risk youth, there is no evidence that this event triggered a formal risk review, outreach by mental health services, or coordinated interagency support. This was a critical missed opportunity for intervention during a period of heightened risk.147 (Emphasis added) e. Inadequate follow up after Crisis Connect Assessment: When mental health clinicians assessed Child RK on 4 December 2021 following an incident of self-harm, an elevated risk profile was identified, although an assessment the following day determined Child RK was no longer at elevated risk.
However, given the known fluctuations in suicidality (especially in young people) it is of concern that no referrals were made to mental health services, and Child RK’s case manager was not contacted. I also agree with Dr Wojnarowska’s assessment that: While such an approach may be procedurally acceptable in adults, it was insufficient in RK’s case, given her age, history of disengagement, and known risk factors”.148 145 See for example: ts 05.11.25 (Willsher), pp21-24 146 ts 05.11.25 (Willsher), p39 147 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p18, para 115 148 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p19, para 116
[2025] WACOR 53 f. Failure to conduct care plan reviews: Ms Fabry explained the importance of care plan reviews in these terms: The policy requires that when there’s a significant change in a child’s life, we should be reviewing the care plan…So at the point in time we are talking, we knew there was a change in care arrangement coming, it would have been…best practice. So, the legislation didn’t require it, but it would have been best practice to have held a care plan review, so that we could look at what the legislation sets out. The purpose of the forum is to identify a child’s needs, set out the steps and measures to address those needs. What’s also relevant about that forum is it’s not only based in the Act. The decisions are called care planning decisions.
They’re then reviewable to the care plan review panel that sits in my team in the specialist child protection unit, and then if one of the parties still is not happy with a decision, they can go to the State Administrative Tribunal…So it’s a very formal process, to make sure that we’re making good decisions, and that the right people have the input into the child’s needs.149 Ms Fabry also noted that care plan reviews had not been conducted prior to critical changes in Child RK’s care placements. At the inquest, Ms Fabry made the following observations about the management of Child RK’s placements after her foster carer placements had broken down: I think that the missed opportunity was to step back. So, it’s the nature of case work is that you’re very involved in the child’s life, and they were involved and trying to support (Child RK) through a complex transition, where she was finishing in one care arrangement. That’s a policy decision that has now changed. She wouldn’t have had to have left Accordwest care under the model now, but I guess (Child RK’s) behaviour escalated. It’s sort of reject rather than be rejected. She then took the decision, “I’m moving.” There was some placement instability before we got her to National Park House. So, it was a complex time for her between care arrangements. Whether it’s actually not the best time to plan. It’s best to plan before that happens, and that’s why the…policy requirement is to say, “We’ve got a big transition coming up. Let’s come together before then so we navigate that period”.150 149ts 06.11.25 (Fabry), pp144-145 150 ts 06.11.25 (Fabry), p147
[2025] WACOR 53 Comments on quality of Child RK’s supervision, treatment and care
I accept that the Department made considerable efforts to place Child RK into appropriate and safe foster care placements, and that despite counselling and regular respite care, these placements broke down because of Child RK’s extremely challenging behaviours. Nevertheless, as I have outlined, there were missed opportunities where Child RK’s care could, and should have been improved. In making that observation, I make no particular criticism of Child RK’s caseworkers.
At the inquest Ms Watters said that at the relevant time, her caseload included 14 children in care, one of whom was expressing suicidal ideation on a daily basis. I was concerned that because of her caseload, Ms Watters said she was only able to see Child RK face-to-face about once per month in the period 2019 - 2020, although Ms Watters said she spoke to Child RK weekly by phone.151,152
I accept that restrictions related to the COVID-19 pandemic affected face-to-face meetings in the first half of 2020. However, given the issues impacting on Child RK and her complicated placement history, it is difficult to accept that this level of contact was appropriate.
I accept that caseworkers do their best to ensure the safety of children in care, however by definition children in care have complex presentations.
After assessing the evidence of Ms Watters and Ms Fabry, I have concerns about current levels of awareness of some caseworkers as to the complex needs of children in care.
At the inquest, Ms Fabry explained the role of the child safety practitioner (i.e.: caseworker) in these terms: [C]child safety practitioners…come in with a social work degree, or a psychology degree, or something similar. The expectation for them to know intimately every service, understand every complex system - the child and adolescent mental health system is complex, let alone the health system, the education system, the National Disability Insurance Scheme. So, they’re somewhat generalist, and…we have a suite of supports around case management staff.154
Whilst I accept Ms Fabry’s evidence, and I acknowledge the supports available to caseworkers (including regular supervision) I am not convinced that caseworkers managing children in care are sufficiently aware of the complex psychological, behavioural, and polysubstance substance issues experienced by many of those children.
I am also concerned some caseworkers may not be sufficiently aware of relevant services, such as the Young People With Exceptionally Complex Needs service. In my view, additional training on the complex needs of children in care would be of value to caseworkers, as would training to help caseworkers better identify the “red flags” that may place some children at increased risk of self-harm or suicide.155,156
In Child RK’s case, there was a failure to identify the cumulative negative impact of various issues, including: her disengagement from psychological counselling and school; the death by suicide of her close friend Child K; Child RK’s expressions of suicidal ideation and increasing self-harm; and Child RK’s known anxiety about placement changes, especially the change that occurred in August 2021.
I have therefore recommended the Department provide additional training to caseworkers (and other relevant staff) to enable them to better understand the complex experienced by many children in care, and to better identify those children at increased risk of self-harm.
154 ts 06.11.25 (Fabry), pp160-161 155 ts 05.11.25 (Watters), pp86-88 156 As to whether caseworkers should receive additional training, see: ts 05.11.25 (Watters), pp66-68
While RK’s risk profile was chronic and difficult to fully mitigate, a more proactive, integrated response - particularly at key moments of deterioration - may have improved support and reduced the likelihood of a fatal outcome.157
I agree with Dr Wojnarowska’s observation, and I note that with the benefit of hindsight, there were several missed opportunities where Child RK’s care could and should have been enhanced.
However, for the avoidance of doubt, I have concluded that on the basis of the available evidence (and given the unpredictability of suicide) it is not possible for me to conclude (to the relevant standard) that any particular action at any particular time would necessarily have altered the outcome in Child RK’s case.
157 Exhibit 1, Vol. 2, Tab 31.1, Report - Dr G Wojnarowska (31.10.25), p19, para 117
[2025] WACOR 53 EVENTS LEADING TO CHILD RK’s DEATH158,159,160,161,162,163,164,165
At about 5.00 pm on 19 April 2022, Child RK and a residential care worker left National Park House (NPH) to travel to an appointment. On the way, Child RK asked him to stop the car, and he did so near a shopping centre. Child RK got out of the car and absconded, and the care worker returned to NPH. Child RK called care workers at NPH at about 9.40 pm from Warwick train station and asked them to arrange a taxi, and she arrived back at NPH a short time later.
At about midnight on 20 April 2022, Child RK was in her bedroom at NPH listening to music. Care workers asked Child RK to turn her music down as it was too loud, and she did so without complaint. At 12.01 am, Child RK made a post on social media, but it was later discovered that incoming messages at 12.47 am, and 1.26 am did not appear to have been read by her.
At about 9.30 am on 20 April 2022, care workers at NPH knocked on Child RK’s bedroom door to wake her up for a Choice Plus appointment, but there was no response. A short time later, another care worker went to enter Child RK’s bedroom to check on her and found Child RK hanging with a mobile charger cable around her neck that was tied to the door handle.
Emergency services were called, and Child RK was cut down and placed on her bed. Ambulance officers arrived at NPH at about 10.05 am and confirmed that Child RK had died. I accept that ambulance officers did not attempt to resuscitate Child RK because she was obviously deceased.166,167,168 158 Exhibit 1, Vol. 1, Tab 2, Report - Coronial Investigator D Sheahan (undated) 159 Exhibit 1, Vol. 1, Tab 2.1, Memorandum - Sen. Const. DC Sheahan (20.04.22) 160 Exhibit 1, Vol. 1, Tab 12, Shift Report - National Park House (19.04.22) 161 Exhibit 1, Vol. 1, Tab 16, Statement - Ms E Aitken (20.04.22) 162 Exhibit 1, Vol. 1, Tab 18, Statement - Child SE (15.06.22) 163 Exhibit 1, Vol. 1, Tab 19, Statement - Mr JM Clarkson (08.11.22) 164 Exhibit 1, Vol. 1, Tab 20, Summary of events - Ms T White (01.07.22) 165 Exhibit 1, Vol. 1, Tabs 22 & 22.1, Therapeutic Care Services Critical Incident Report (20.04.22 & 20.04.22) 166 Exhibit 1, Vol. 1, Tab 3.1, St John Ambulance Patient Care Record 21437481 (20.04.22), p2 167 Exhibit 1, Vol. 1, Tab 3.2, St John Ambulance Patient Care Record 21437482 (20.04.22), p2 168 Exhibit 1, Vol. 1, Tab 4, Life Extinct Form (20.04.22)
On 22 April 2022, a forensic pathologist (Dr White) conducted an external post mortem examination of Child RK’s body at the State Mortuary, and reviewed post mortem CT scans.171,172
In her supplementary post mortem report, Dr White noted: “External only examination has shown a young adolescent girl with an evident ligature mark to the neck and evidence of previous self-harm”.173
Toxicological analysis of samples of bodily fluids taken from Child RK’s body did not detect alcohol, tetrahydrocannabinol or common drugs in her system.174,175
At the conclusion of the post mortem examination, Dr White expressed the opinion that the cause of Child RK’s death was ligature compression of the neck (hanging).176
I respectfully accept and adopt Dr White’s conclusion with respect to the cause of Child RK’s death and I find that Child RK died after she hanged herself with the intention of taking her life.
In view of all of the circumstances, I find that Child RK’s death occurred by way of suicide.
169 Exhibit 1, Vol.1, Tab 7, Supplementary Post Mortem Report (24.05.22) 170 Exhibit 1, Vol.1, Tab 7.1, Post Mortem Report (22.04.22), p1 171 Exhibit 1, Vol.1, Tab 7, Supplementary Post Mortem Report (24.05.22) 172 Exhibit 1, Vol.1, Tab 7.1, Post Mortem Report (22.04.22), p1 173 Exhibit 1, Vol.1, Tab 7, Supplementary Post Mortem Report (24.05.22), p1 174 Exhibit 1, Vol.1, Tab 8, Urgent Interim Toxicology Report (27.04.22) 175 Exhibit 1, Vol.1, Tab 8.1, Final Toxicology Report (11.05.23) 176 Exhibit 1, Vol.1, Tab 7.1, Supplementary Post Mortem Report (22.04.22), p1
[2025] WACOR 53 CURRENT AND FUTURE INITIATIVES Department initiatives
[2025] WACOR 53 f. Critical incident policy: updates to the policy promote “timely notification to senior leadership in the event of a critical incident and facilitates effective operational response to critical incidents”;183 g Care planning project: this project aims to improve compliance with, and the quality of care-planning for children in care;184 h Role of clinical staff in child protection: the Department has implemented a new framework to guide the work of psychology and allied health staff, including “clear guidance” on the role of psychologists in responding to children at self-harm and suicide risk.185 At the inquest, Ms Fabry also said this about the new role of departmental psychologists: We’ve recently made some changes to our clinical services framework.
So, our in-house psychologists, now 25 per cent of their time is to be spent with family and foster carers, to be supporting them.186 i. At Risk Youth Strategy: the Strategy (released in September 2022) aims to “strengthen responses for young people aged 10 to 24 years with multiple and complex problems who are at risk of harm and have increased vulnerability of experiencing poor life outcomes”;187 j. Training initiatives: the Department has provided training to assist staff to identify and manage children at risk of self-harm and suicide;188 and k. Child Safe initiatives: the Department has embarked on initiatives aimed at ensuring its procedures and policies are “child safe”.189 CAHS initiatives190,191
183 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), p14 184 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), p15 185 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), pp15-16 & ts 06.11.25 (Fabry), pp138-139 186 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), pp15-16 & ts 06.11.25 (Fabry), pp138-139 187 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), pp16-17 188 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), pp17-18 189 Exhibit 1, Vol. 1, Tab 23.1, Supplementary Report - Ms A Fabry (26.10.25), p18 190 Exhibit 1, Vol. 2, Tab 34, Report - Dr V Padmanabhan (24.10.25), pp7-11, paras 56-102 191 See also: ts 06.11.25 (Padmanabhan), pp114-127
The supports currently available for children with complex health needs include crisis response initiatives (including an acute care and response team, and Crisis Connect), community mental health services, and an intensive day program. In his report Dr Padmanabhan also touched on staffing issues, and noted that “Recruitment, especially of psychiatrists remains the most significant barrier to service capacity”.192
The Stepped Model outlined by Dr Padmanabhan in his report is a way of more effectively addressing: “the needs (of) children in care with moderate to severe mental health challenges in a structured and graduated manner. Dr Padmanabhan also said that the Stepped Model “would build on the stepped model of services that was adopted by the ICA Taskforce”,193 and he explained its purpose in these terms: [T]o ensure that children in care have access to continuity of care at the right level of intensity - from outpatient therapy to interagency traumainformed programs to secure therapeutic stabilisation, as necessary.
Rather than looking at individual services in isolation, there should be broad capacity to meet the needs of children across the continuum of care, including capacity to “step up” and “step down” the care as required. This model mitigates the risk of children, who are unable to be sustained by mainstream services due to high levels of risk and complexity, from falling into gaps between services.194
[2025] WACOR 53 c. Step 3: this level of care is required for those children in care “with presentations that include complex trauma, high risk behaviours, repeated absconding and comorbid mental health issues may require intensive care for up to three months to stabilise their condition, undertake required assessments and to provide therapeutic treatment”.197
In my view, the Stepped Model is worthy of detailed consideration. I have therefore recommended the Department and CAHS enter discussions with DoH to determine the feasibility of adopting the Stepped Model to address the complex needs of some children in care.
Dr Padmanabhan explained the importance of greater collaboration between relevant agencies, noting that: The core principles underpinning the trauma-informed model of care are safety, trustworthiness, collaboration, empowerment, and cultural responsiveness. Children must experience physical and psychological safety across placements, schools and health. Agencies must act transparently, share information appropriately, and provide predictable responses to crises. Collaboration requires joint planning and accountability across Communities, CAMHS, Education, education providers, carers, primary health and non-government partners.
Extended partners may include disability services, youth justice, housing and police. Cultural safety, particularly for Aboriginal children, is essential.198
(a) The Child and Adolescent Health Service (CAHS) lead, in collaboration with the Department, and the Mental Health Commission, work to determine the feasibility of implementing a service to provide assertive mental health care for children in the care of the CEO of the Department; and
(b) The Department lead, in collaboration with the CAHS, work to examine the feasibility of adopting a new dedicated secure therapeutic facility model of service for children in the care of the CEO of the Department.
Recommendation No. 2 The Department of Communities should, in consultation with the Young People with Exceptionally Complex Needs service’s key stakeholders and agency leads, consider the feasibility of broadening the program’s remit beyond its current eligibility criteria, so that it could serve as an escalation point for cases involving children in care such as Child RK.
[2025] WACOR 53 Recommendation No. 3 The Department of Communities should provide additional training to caseworkers (and other relevant staff) to enable them to better understand the complex psychological, behavioural, and substance issues needs of many children in care and to better identify trauma behaviours that may place those children at increased risk of self-harm or suicide.
Comments on recommendations
In an email dated 10 November 2025, Mr McDonald (Counsel Assisting) forwarded a copy of the draft recommendations I proposed to make to lawyers for the Department, and three of Child RK’s former foster carers (i.e.: Ms B, Ms C, Ms D and Ms E). Any feedback was requested by close of business on 8 December 2025, and Mr McDonald sent a reminder email on 2 December 2025.200,201
By way of an email dated 8 December 2025, Ms Keighery requested an extension for the provision of feedback, noting that the “cross-agency response” that was being worked on was taking longer than expected.
An extension was granted until 12 December 2025.202
[2025] WACOR 53 inclusion of the Department of Education in a (MoU) with the Department of Communities.203
As to Recommendation 3, Ms D agreed that training “benefits all staff” but added that the success of such training must be measured, and that: One effective approach is consultation with significant family members or significant carers in the child's life, which would assist the Case Manager and Team Leader. Involving a carer or family member the child trusts can reinforce and validate their emotions, helping to put them at ease and increasing their confidence in staff within the Department of Communities and hopefully, minimising lost "red flag" opportunities.204
By way of an email dated 7 December 2025, Ms E advised that she agreed with Recommendations 1, 2 and 3, but she would like Recommendation 3 to be extended: [T]o include the Department of Communities also providing this additional training to carers/significant others of children who are exhibiting complex behaviours that increase their risk of suicide or selfharm.205
In her email, Ms E also provided some feedback about the care provided to Child RK whilst she was in care. One of the issues Ms E mentioned was the limited contact Child RK apparently had with Ms B and her siblings after the breakdown of that care placement. Ms E also questioned whether there are sufficient multidisciplinary case conferences for children in care, noting the potential benefits of such collaborations.206
By way of an email dated 8 December 2025, Ms C advised that she agreed with the three Recommendations, and in respect to Recommendation 3, Ms C expressed some concerns about Child RK’s caseworker and said that in her (Ms C’s) view: 203 Emails - Ms D to Mr D McDonald (07.12.25) 204 Emails - Ms D to Mr D McDonald (07.12.25) 205 Email - Ms E to Mr D McDonald (07.12.25) 206 Email - Ms E to Mr D McDonald (07.12.25)
[2025] WACOR 53 [T]here needs to be a system where caseworker decisions are moderated by others, case management needs to be just that, management by many.207
Ms C also said that in her opinion, concerns raised by carers about Child RK’s caseworker were ignored, and that when Child RK was in the residential group homes, there was a “revolving door” of carers, none of whom Child RK confided in. Ms C also said that in her view: I feel that we can only move forward (if we) make sure that all decisions are moderated effectively and that those who have genuinely cared for these children are consulted.208
On 12 December 2025, Ms Keighery sent an emailed a letter from the Director General of the Department of Communities (Mr Mike Rowe) setting out the Department’s response to the Recommendations.209 The Department’s response may be summarised as follows: a. Recommendation 1: the Department raised some concerns in relation to the “medium term containment” recommended by Step 3 of the proposed stepped model of care, and noted legislative amendments would be required. Nevertheless, “In consultation with the relevant stakeholders representing CAHS and the Child and Mental Health Service (CAMHS)”210 the Department proposed an amendment to Recommendation 1, the substance of which I have adopted.
b. Recommendation 2: the Department suggested a minor amendment to this recommendation, which I have adopted.
c. Recommendation 3: the Department suggested a minor amendment to this recommendation, which I have adopted. The Department also noted: Communities considers it is inappropriate for Child Safety Practitioners to evaluate risk of self-harm or suicide as these necessitate specialised clinical expertise from registered mental 207 Emails - Ms C to Mr D McDonald (08.12.25) 208 Emails - Ms C to Mr D McDonald (08.12.25) 209 Email - Ms S Keighery (State Solicitor’s Office) to Mr D McDonald - Attached Letter: Department’s response (12.12.25) 210 Letter - Mr M Rowe, (Department of Communities) to the Court (12.12.25), p3
[2025] WACOR 53 health professionals to ensure accurate diagnosis and intervention.211 While I agree with this observation, with respect, that is not at all what Recommendation 3 is seeking to address.
On any plain reading, Recommendation 3 is clearly concerned with providing better training to child safety practitioners (i.e.: caseworkers) and other relevant staff, to help them identify children at increased risk of self-harm or suicide. Once a child in care has been identified as being at risk of self-harm or suicide, the obvious next step would be to involve “registered mental health professionals” to assess the child’s level of risk and provide treatment as appropriate,
211 Letter - Mr M Rowe, (Department of Communities) to the Court (12.12.25), p4 212 Email - Ms S Keighery (State Solicitor’s Office) to Mr D McDonald - Attached Letter: CAHS’s response (12.12.25) 213 Attachment A to Letter - Ms V Buić (Child and Adolescent Health Service) to the Court (12.12.25), p1 214 Letter - Ms V Buić (Child and Adolescent Health Service) to the Court (12.12.25), p1 215 Letter - Ms V Buić (Child and Adolescent Health Service) to the Court (12.12.25), p1
[2025] WACOR 53 c. Recommendation 3: CAHS suggested a minor amendment to this recommendation in the same terms as suggested by the Department. As noted earlier, I have adopted the suggested amendment.
Child RK was a creative, intelligent young woman with a loving nature, and a good sense of humour. She was also a young woman with complex mental health needs as a result of early child trauma, and she was taken into care by the Department when she was only 4 years old.
After carefully assessing the available evidence, I have concluded that there were missed opportunities where Child RK’s care could have been improved. However, I have not been able to conclude that any particular action at any particular time would necessarily have altered the outcome in Child RK’s case.
I have made three recommendations relating to greater integration of available services, and enhanced training for caseworkers respectively.
These recommendations were shaped by feedback from the Department and CAHS, and I sincerely hope the recommendations will be enthusiastically embraced and fully implemented.
The death of a loved one is always a sad occasion, but Child RK was only 14 years old when she took her life on 20 April 2022. The death of such a young girl in such truly awful circumstances, is almost an unfathomable tragedy.
Child RK had her whole life in front of her. There were so many things she was yet to experience, and so many things she was yet to enjoy. I simply cannot imagine the grief and sadness that Child RK’s death has caused to those who knew and loved her.
It is a common misconception that at some point after a loved one’s death there is “closure”. Those who have experienced profound loss know this is not the case. The aching void left by the loved one’s death does not get filled, nor do the feelings of sadness ever completely disappear.
However, with the passage of time, perhaps the sense of pain and loss becomes a little easier to bear. Memories of happier times emerge, and these can help to deaden the ache caused by the loved one’s death.
It is my sincere hope that those affected by Child RK’s death may have this experience.
In concluding this finding, I wish to extend, on behalf of the Court, my very sincere condolences to all of those who have been touched by Child RK’s death. This includes Child RK’s family (especially her siblings), foster carers, residential care workers, departmental workers, and clinical and other staff who interacted with her.
MAG Jenkin Coroner 17 December 2025
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…
Sean Theo Winmar, a 46-year-old Nyungar Aboriginal man, died by hanging at The Beacon residential facility on 11 August 2022. He was subject to an interim post-sentence supervision order (HRSO Act) following release from…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.