AN INQUEST … families still waiting


Talieha Nebauer passed away in April 2014
Will Fowell died in June 2014 and
Caitlin Wilkinson Whiticker took her life in August 2014

Two of those young people were in the care of the state when they took the actions that would end their lives. The other was living with family who had no access to any information on that young person’s treatment plan or assigned clinicians; state of mind and attendance at sessions; or the appropriate behaviour and support to be adopted by those close to her.

Prior to the closure of the Barrett Centre, families had the security of knowing that their loved ones were so well supervised that they would be safe from the fatal outcomes that their mental health issues could lead them towards. They knew that they were in an environment where they were surrounded by friends who’d look after them, who’d demonstrated the kind of caring that would at least help to nullify the feelings of isolation that had previously plagued them. And, for many, there was the hope that long-awaited progress brings – that one day, they would be leading independent lives in the community with all that things that that entails – study, work, social activities, sport, relationships, a family of their own …

but that ended as the turbulent years of uncertainty and decline led to the disintegration of that understanding community. Young people found themselves in unfamiliar places, sometimes surrounded by adult patients and expected to bear the burden of levels of self-sufficiency that they had no experience with; or living in the community and wielding the rights and authority of adulthood without the maturity or capacity to have such a huge responsibility.

April, June, August 2014.

And still no answers for their families. 

The Barrett Adolescent Centre Commission of Inquiry’s parameters reached to only to one month after patients’ transitioned to new services so, as noted in the Adequate Transitions?’ post, the Commissioner indicated that the immediate and root causes of the deaths of the three former Barrett patients are “matters for the Coroner”.

BUT currently the position of the Coroner’s office is that the Deputy State Coroner is still investigating and is yet to make a final decision about whether an inquest is warrantedIf it is finally determined appropriate to proceed with an inquest, families have been told that it will not be held this year.

It would seem, though, that, based on evidence and information that has long been available, the Coroner’s office could at least confirm that an inquest will go ahead.

This Factsheet from the Queensland Courts website indicates that an inquest will be held “if it is in the public interest” e.g.

  • there is significant doubt about the cause and circumstances of death

  • it may help to prevent future deaths or uncover systemic issues which affect public health and safety. 

And this document outlining the reasons for investigating ‘Deaths in Care’ (which summarises the detail in the State Coroner’s Guidelines) clearly states that “An inquest must be held for deaths in care if the circumstances of the case raise issues about the care that was provided to the deceased person.”

The Coroner’s Act also states that once an application for an inquest is received from a family outlining why it is in the public interest for an inquest to be held (in the case of the deaths of Talieha, Will and Caitlin, there were a number of submissions in 2014 to the Coroner from those within the Barrett community as well as from the families of the young people themselves), the Coroner must make a decision

(a) 6 months after the coroner receives the application; or

(b) the longer period the coroner considers necessary to enable the coroner to obtain relevant information for making the decision.

s30(9) p43

In this case, the Coroner has extended that 6 months due to the holding of the Commission of Inquiry.

But, irrespective of the information to be gained from the evidence given to the Inquiry about the period that ends one month post-transition, it would seem that a number of the factors/circumstances in the deaths of these young people would immediately warrant a decisive announcement from the Coroner on the need for an inquest. The Inquiry into the closure might ADD to those reasons and provide detail to be considered during inquest proceedings but …

  • three young people were in circumstances where they had the motivation and opportunity to end their lives when prior to the closure of the centre where they had received the care that prevented such actions, they were safe, secure and, in some cases, making the progress that would allow them to lead productive, independent adult lives;
  • two of those young people were in the care of government services where the high risk of suicide was known;
  • families and professional experts believe that the closure of the centre where the three were previously accommodated was a factor in the three suicides – because the process had been so destabilising and transitions had been problematic AND because it meant the lack of a statewide service that had proven to be the only treatment option that had a chance of being effective for these young people as well as those with similar levels of severity and complexity.

It would seem very clear that this is in the public interest. Apart from the fact that families remain in limbo about what happened to their children, an inquest would seem the only way to not just examine what occurred but to facilitate recommendations that would ensure such preventable tragedies can’t be repeated. An inquest could lead to referral to other agencies if there’s a need to investigate possible misconduct or if the coroner’s concerns indicate a need for the quality of health care to be considered by a particular regulatory body.

So, confirmation of an inquest seems warranted.

Certainty of some kind is definitely needed. 

With the years of waiting and the months of enduring the rigours of an Inquiry where the trauma of each young person was laid out (a closed court might mean the wider public do not hear the details but family members sat with 3 or 4 rows of legal representatives for the various HHSs, senior bureaucrats and others while the pain of their children’s history was scrutinised), more waiting just to know IF there will be an inquest must seem intolerable to those whose losses impact their lives daily.

They know their children can’t come back.
But don’t they deserve to know why?
Don’t they deserve to at least know that someone sometime will be asking the appropriate people the right questions to find out why?

Don’t the people of Queensland need to know what went so wrong with the care that  should have kept these young people safe and enabled them to make progress in order to ensure that it won’t happen again to anyone else?
Don’t the young people of Queensland deserve to have all the healthcare services that will keep them alive and give them the best chance at a good life because the system has been developed to include services, approaches and attitudes that have been informed by the mistakes and tragedies of the past?

If we can’t learn from what happened, then the losses are even greater.

So … if you believe that an inquest is in the public interest, you can:
Contact the Queensland State Coroner at or
write to: Qld State Coroner, Dept of Justice & Attorney-General, Level 1, Brisbane Magistrates Court, 363 George Street, Brisbane QLD 4000

The families need to know.
The people of Queensland who’ll need healthcare in the future need to know.
But to start with, they just need to know that there’ll BE an inquest.
We hope the waiting can end soon.

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