Inquest into the death of SG

Case Number: 2020/144089

Findings Date: 25 June 2023

Magistrate: Erin Kennedy

CORONIAL LAW | death of Aboriginal child; intentionally self-inflicted; protective care and treatment; recommendations made

Responses

Recommendations

The NSW Department of Education

1. That the Department of Education (DOE) implements a policy to ensure that a copy of any prior child protection history is accessed by school counsellors at the time of, or shortly after, meeting with suicidal students so that an assessment of cumulative trauma and post-traumatic stress can be more accurately obtained at the time of presentation to a counsellor.

2. That the DOE undertake a comprehensive review of current policies across all schools and implement a clear suicide and wellbeing policy, ensuring that the policy considers the following:

a. the mandatory delivery of a suicide prevention or safety plan for all students reporting suicide attempts be implemented as soon as possible after a suicide attempt;

b. if a safety plan is not developed or implemented for any reason, the reasons for this decision are documented and signed off jointly by the school principal and school counsellor, and parents/carers and other agencies (if involved) are informed;

c. a mandatory checklist be developed to ensure all school staff are clear on the precise steps required, and the allocation of roles and responsibilities when there is a suicide attempt;

d. provide information and adequate resources to provide immediate support to staff, parents and students in the event of suicide attempts or suicidal behaviour;

e. ensure that steps required under the policies of the DOE are enacted at the local level;

f. implement a mandated and automatic system for follow-up by school counsellors, which is not dependent upon individual capacity or memory; and

g. implement an additional level of oversight for when a mandatory report or e-referral to DCJ is sent to the principal and deputy principal which does not permit human error to allow the child or young person to be unsupported.

3. That an education and training package be delivered to school staff (including principals, deputy principals, teachers and school counsellors) to ensure policies relating to student wellbeing and suicide at a local and state level are being followed; and provide comprehensive and practical training on responding to a suicide attempt or suicidal behaviours.

The Department of Communities and Justice, the NSW Department of Education, Child and Adolescent Mental Health Service and the Hunter New England Local Health District

4. Consideration be given to developing a joint agreement between the Department of Communities and Justice, NSW Department of Education and the Child and Adolescent Mental Health Service, Hunter New England Local Health District so as to ensure cooperation, coordination, communication and information sharing takes places in an appropriate and timely manner in accordance with the provisions available under Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998, to ensure that:

a. records and information are shared between the agencies, as appropriate, when a report is made regarding a child or young person

b. where an agency relies on the involvement of an external agency in a decision making process, then each agency must notify the external agency if no further action is to be taken by their staff, and

c. the agencies must implement a memorandum of understanding or policy to mandate that staff follow up with counterparts at the other agencies so that appropriate action for the young person occurs.

The NSW Department of Education, Child and Adolescent Mental Health Service and the Hunter New England Local Health District

5. That an education package is developed by the above agencies to provide to parents and carers of children or young people who have attempted suicide or expressed suicidal behaviour. The package is to provide guidance in relation to dealing with suicide attempts, suicidal behaviour, initiating appropriate conversations with young people in relation to same, and general suicide and wellbeing education for parents, particularly around the possibility of any further attempts of suicide and risk factors. Such a package should be provided to parents following a report to a school counsellor or a referral to CAHMS about such behaviours.

The Department of Communities and Justice

6. To give consideration to the risk of suicide, including the weight given to a child’s previous suicide attempts, within the comprehensive Prioritisation, Triage and Allocation Policy Review to ensure better identification and prioritisation of children most at risk.