From Death We Learn 2009

1. From Death We Learn 2009 Inquest of twenty-two Kimberley Aboriginal people Office of Safety and Quality in Healthcare Reference: Kimberley Report on Miscellaneous Aboriginal Deaths February 2008

2. The Case In February 2008 the State Coroner released his inquest findings into the deaths of 22 Aboriginal people in from the Kimberley region of Western Australia The inquest was conducted in the setting of: • an increasing suicide rate in Aboriginal Kimberley people • deaths that appeared to have been caused or contributed to by alcohol and cannabis use

3. The Inquest In relation to Aboriginal Kimberley people, Mr. Hope noted: • An increase in self harm rates compared with the non-Aboriginal population. This increase was particularly noted in Fitzroy Crossing; • Appallingly bad living conditions for many, and in particular children; • High rates of fetal alcohol syndrome.

4. The Case In relation to Aboriginal Kimberley people inquest revealed: • No realistic leadership and a lack of accountability from any agency in response to living conditions; • Very poor health compared to other Western Australians; • A widening ‘gap’ in wellbeing between Aboriginal and non-Aboriginal people • despite funded Commonwealth and State programs targeting indigenous people; • No single individual or organization in government responsible for achieving outcomes for Aboriginal people; • Levels of educational achievement with skills inadequate for employment in the majority of students; • Public housing in a disgraceful condition; • Aboriginal people experiencing a health crisis; • Alcohol abuse as the cause and as a result of many of the problems facing many Aboriginal people; • Serious challenges and extreme difficulty in providing comprehensive mental health and drug and alcohol care.

5. The Inquest The WA State Coroner Concluded: • “That such conditions should exist among a group of people defined by race in the 21st century in a developed nation like Australia is a disgrace and should shame us all”. (Adopted from SA State Coroner, Mr Wayne Chivell) • urgent action is required to address living conditions • There was strong support for change among a wide range of committed people throughout Western Australia and particularly from many Aboriginal people.

6. Outcome • Inquest documents the cause of death of 22 people • The State Coroner made 27 recommendations for multiple government departments

7. Key Message • The Aboriginal Kimberly people are suffering a complex social and health crisis.