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Coroner's Act In the matter of Coroner's Findings and Recommendations into the death of Kunmanara Forbes pursuant to section 46B dated 2 December 2009



Coroner's Act In the matter of Coroner's Findings and Recommendations into the death of Kunmanara Forbes pursuant to section 46B dated 2 December 2009

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Tabled paper 660


Tabled papers for 11th Assembly 2008 - 2012; Tabled papers; ParliamentNT




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down, as they so obviously were. There was no family around, no consistent family member taking responsibility for this girl to help to set her on the right track and to make sure that she had the appropriate assessments and the help that would come from those assessments. So all of thats missing. And she had a whole lot of physical and behavioural concerns that would have or should have raised her case to a higher level basically ... ...there are two agencies that if they were involved should have, could have and should have picked up the severity of this case and severity of risk in this case and done something more about it. The first is Family and Childrens Services and the second is Remote Mental Health Service. ( (Transcript p 30) ...when I was reading through the file knowing the outcome as we do, it was almost like seeing a horror movie where you know whats going to happen at the end and you just want someone to ask the particular questions or Q All the flags were there and no one particular picked up how serious it was? A No one put it all together. I think that people did pick up that there were some serious things here, some serious things there, but no one actually brought the case together. no institution or no one in \ 38. Given the lack of effective involvement of Remote Area Mental Health (discussed above) it was Dr Rosebys view that FACS had a responsibility to pull the case together (Transcript p31 -32). Although Ms Scott gave a somewhat qualified assent to this proposition (Transcript pi22-123), the contrary was not put to either Dr Roseby in questioning nor me in submissions by counsel for FACS. I find that in all the circumstances FACS was the appropriate organisation to organise a case conference and should have done so in relation to the deceased, so that the disparate pieces of information about her physical and mental health, wellbeing, and whereabouts which were in the hands of different organisations could be 15

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