“Many of the children suffered from largely preventable medical conditions... related to sub-standard living conditions,” she said. The packed court heard most of the children experienced dysfunction and alcohol abuse in the home environment, with some witnessing severe domestic violence. Some were drunk when they suicided and most knew relatives who had previously taken their own life. The situation in the Kimberley region is dire and children and young persons have continued to die by suicide, despite the valiant efforts of service providers... Coroner Ros Folgliani Ms Fogliani said the inquest laid bare the deep inequalities in remote communities.

Among her 42 recommendations were restrictions on takeaway alcohol services, a voluntary cashless welfare card trial and voluntary options for children to attend residential schooling. “The situation in the Kimberley region is dire and children and young persons have continued to die by suicide, despite the valiant efforts of service providers, despite the increased governmental funding, despite a better understanding of the importance of being culturally competent, and despite the numerous initiatives being implemented to avoid these preventable deaths,” she said. “The considerable services already being provided to the region are not enough. “It may be time to consider whether the services themselves need to be co-designed in a completely different way, that recognises at a foundational level, the need for a more collective and inclusive approach towards cultural healing for Aboriginal communities.” More research and services for children with foetal alcohol syndrome, a Commissioner for Aboriginal Children and Young People and more local community liaison officers to assist families to access services also formed part of the Coroner's recommendations.

Aboriginal Senator Patrick Dodson said he hoped the inquest findings would not "sit and gather dust" like some other reports into Aboriginal well being. "This inquiry confirms what we already know – we have a crisis in the Kimberley," he said. "The rate of suicide in the Kimberley by Indigenous people, in particular young Indigenous people, is amongst the highest in the world. "Ten years have passed since the last major inquiry into the deaths of young Indigenous people – the Hope Inquest. "Today confirms yet again, we have made little or no progress."

The inquest report made a number of adverse findings against the Department of Child Protection and Family Support in relation to four of the young people, including a 10-year-old girl from Looma Aboriginal Community, whose shocking suicide in 2016 led to the inquest. The findings detailed occasions when the agency failed to assess allegations of violence and neglect flagged by social workers, carers and anonymous members of the community. The department, during the inquest, conceded that in hindsight it should have acted and that it had since changed some policies to address the short falls. The state government has made a commitment to work with Aboriginal communities to allow local people more input into policies that impact them. In its submission to the inquest, it said the changes would be a “significant shift in policy” and would require time to “nurture and embed”.

Ms Fogliani said the shift would require the principals of self-determination and empowerment and would also require significant funding. Families of the deceased children and young people listened to the findings be handed down via video link from Broome, Halls Creek, Kununurra and Fitzroy Crossing. The recommendations at a glance Recommendations regarding FASD 1. Universal screening for FASD during infant health assessments and upon a child entering into the child protection system or justice system for the first time; all children at risk of brain damage due to trauma or alcohol exposure in the womb be assessed for impairments at one year old and in the year before entering school; that comprehensive IQ and functioning assessments be done where required; there be referrals to other treatment services for trauma-related impairments, developmental and behavioural issues

2. Neurodevelopmental impairment (an umbrella term which includes behavioural, developmental and cognitive impairments) be recognised as a diability under the NDIS; Severe FASD be separately recognised as a disability within the NDIS 3. The government consider including FASD treatments under Medicare Benefits Scheme 4. GPs in areas with high burdens of neurodevelopmental impairment get additional funding to improve diagnosis and services 5. The government expand the Fitzroy Valley’s Making FASD History project throughout the Kimberley 6. High school students throughout WA get education campaigns about FASD

7. That the state government appoints a special Commissioner or Advisor for Aboriginal children Recommendations regarding alcohol abuse 8. Restrictions on the purchase of takeaway alcohol across the entire Kimberley* 9. That the state consider the possibility of a Banned Drinker register, modelled on therapeutic support* 10. That police be resourced to enforce laws against ‘sly grogging’

11. Local Aboriginal-operated street patrols get secure long-term funding General recommendations 12. Local Aboriginal Area Co-ordinators or Family Advocates assist families to access service providers 13. Consider funding culturally appropriate short-stay accommodation in Kununurra for Aboriginal people visiting the East Kimberley to reduce demand for social housing 14. Transitional Housing Project continue in Broome, Derby, Halls Creek and Kununurra and extend to other town sites in the Kimberley

15. Kimberley people in public housing not be disadvantaged if they start earning money above the eligibility threshold 16. Expand support service The Yiriman Project, which aims to protect young people by strengthening their cultural connection to country 17. Ensure ongoing strategies for addressing suicide are designed and implemented in consultation with Aboriginal people 18. Introduce measure to increase reporting of domestic violence including considering laws to allow for visually recorded statements taken from victims to be admitted as evidence-in-chief in court 19. Provide cultural training for service providers on effects of trauma and FASD

20. Give regular training in suicide intervention to child protection workers and public/private schoolteachers who deal with Aboriginal children 21. Make efforts to bridging courses, cadet programs, and training courses that will allow local Aboriginal people to be employed in health, child protection and police 22. Consider extending an offer of a voluntary cashless debit card program to include the entire Kimberley 23. Expand use of video-conferencing for mental health assessments throughout Kimberley 24. Mental health treatment plans for Aboriginal persons offer option to include traditional cultural healing

25. Government fund more cultural healing projects in Kimberley such as that at Nyamba Buru Yawuru Centre in Broome 26. Kimberley service providers operate in “trauma informed model” and take account of the need for trauma-specific care 27. Better train Kimberley heath workers to assess and care for people with substance abuse and mental health issues 28. Build or undertake a feasibility study for a centre in the East Kimberley that incorporates co-morbid treatment of mental health and substance abuse issues 29. Kimberley health workers to incorporate mental health treatment into perinatal and infant care through resources of the WA Perinatal Mental Health Unit

30. Establish or refurbish youth centres in the Kimberley* 31. Base a mental health clinician in Halls Creek or increase clinician visits 32. Kimberley police stations consider running something like the “Adopt-A-Cop” program in Halls Creek* 33. Expand Halls Creek Elders Reference Group model throughout Kimberley towns, recognise this work through the CDP 34. Develop and fund children and young people’s drug and alcohol rehab in the Kimberley, with step-down processes

35. Maintain early education programs such as Kindylink for the Kimberley with consideration for funding beyond the period of the pilot* 36. Encourage and resource Kimberley schools to introduce re-engagement classrooms at a primary school level. 37. Provide Kimberley high schools with facilities enabling non-academic students of all genders to engage in vocational programs 38. Department of Education expand teaching of Aboriginal languages through Kimberley schools* 39. Link the expanded Yiriman Project to Kimberley schools