A traumatised nine-year-old girl who killed herself while in foster care was "not sufficiently supported" by the Territory Families department, which "largely ignored" its own placement policy for Aboriginal children, the Northern Territory coroner has found.
The girl, referred to by the pseudonym "Sammy", took her life in March last year at the home of her non-Indigenous foster family, who had cared for her since she was 20 months old.
In findings released today, coroner Elisabeth Armitage said Sammy had endured "significant hurdles and trauma", including removal from her parents at the age of 10 months.
"That a child of nine years of age had the knowledge and aptitude to understand death and the wherewithal to kill herself is confronting," Ms Armitage said in her findings.
"That there were apparently no indicators that she was thinking of death and wishing to end her life is troubling."
Ms Armitage said the department had failed to follow through on proposed treatment for Sammy's trauma nor had it assessed her for Foetal Alcohol Spectrum Disorder (FASD), despite her higher risk of suicide as a child in out-of-home care with attention deficit hyperactivity disorder (ADHD).
"Sammy was in the high-risk cohort," Ms Armitage said.
"She was not sufficiently supported."
Sammy struggled with lifelong trauma
The coroner said there was limited information about Sammy's life before she and her older brother were removed from their family.
"What she had suffered prior to that time is unknown, but it certainly involved alcohol, domestic violence, being dropped and suffering her body covered in scabies," Ms Armitage said.
The siblings were initially put in a "Purchased Home Based Care placement" with non-Aboriginal carers, before being placed with other non-Aboriginal carers when Sammy was 20 months of age.
"By that stage, she was clinging to her carer and crying when the carer gave attention to other children," Ms Armitage said.
The coroner described Sammy's long-term foster carers as "some of the very best" and noted that, during her early years at primary school, she was an enthusiastic and sociable child with many friends.
But she had "severe" language difficulties and struggled to concentrate.
As she grew older, she was prescribed the drug Ritalin, and lost her confidence.
"Overmedication may have contributed but it is by no means the only explanation … it is also likely that the trauma in her life was becoming an issue," Ms Armitage said.
'Impulsivity' not the primary reason for death
An examination of Sammy's iPad in the weeks before she killed herself showed she had searched online for what happened to three deceased people, including a nine-year-old Darwin child who died accidentally on play equipment a year earlier.
Footage from security cameras outside Sammy's house captured her movements prior to her suicide on March 14 last year.
It showed Sammy had been playing with other children-in-care, who also lived at the home, before she and another child were requested to tidy up a play area.
An hour later, Sammy was found unresponsive by her carer and was taken by ambulance to Royal Darwin Hospital but could not be revived.
The coroner found "impulsivity" was not the primary reason she died, pointing to two notes the child had written, including one that was an apology to her parents for her death a fortnight before she suicided.
Department faces criticism for failures
Ms Armitage was critical of Territory Families for failing to have Sammy placed in kinship care after being removed from her biological parents, despite repeated requests over several years from her mother and other family members.
Under the Care and Protection of Children Act, Aboriginal children in care are supposed to be placed with a member of the child's family, an Aboriginal person in the child's community, or another Aboriginal person.
"That section [of the Act] was largely ignored and not followed," the coroner said.
In its initial response to the coroner, Territory Families acknowledged that "further exploration of possible family care arrangement should have taken place, particularly during [Sammy's] early years".
However, the coroner said, the department later tried to "minimise those concessions".
"That seems curious, given that Sammy was never placed with her family, community or an Aboriginal carer," the coroner said.
Ms Armitage recommended Territory Families ensure that the placement of Aboriginal children conforms with the Act.
Coroner calls for more trauma assessment and therapy
The coroner was also critical of the department's handling of Sammy's seemingly recognisable traumas, which were "never treated".
Ms Armitage pointed out that Territory Families sought to have the girl included in a play therapy program in 2018, but it never happened.
She also said Sammy was never assessed for FASD, despite the department's own policy requiring children in her situation to be screened for the disorder.
The coroner said children in out-of-home care, particularly with ADHD, were at a higher risk of suicide.
Ms Armitage recommended that all children in out-of-home care receive assessment for trauma and, if necessary, trauma therapy.
In a statement, Territory Families extended its deepest sympathies to the family, friends and communities of the girl.
It said it accepted the recommendations of the coroner and had already implemented numerous reforms following the Royal Commission into the Protection and Detention of Children in the Northern Territory.
"The safety and wellbeing of children and families is our utmost priority and our focus is to improve outcomes for all children and young people, and especially for those who are vulnerable and at risk of abuse, neglect or exploitation."