The WA Coroner has handed down her findings in the case of a young Kimberley boy who killed himself while in state care, saying his death occurred at the end of a life of "profound sadness".
An inquest into the death of the 15-year-old, known only as Child J, was heard in Broome last year, four years after he took his own life following a break-up with his first girlfriend.
The inquest heard the boy had a long history of trauma due to his father's jailing and his mother's escape from a violent relationship, and that his fractured relationship with care placements and mental health providers contributed to his turbulent life ending in 2017.
Throughout the inquest, Coroner Sarah Linton heard about the Indigenous boy's relationship with the Department of Communities.
Child J had 34 separate living arrangements by the time he reached 15 and faced a revolving door of 30 case workers in 13 years.
There were also two failed attempts at reunification with his parents, one which ended when the boy's father failed to collect him after a holiday over Christmas in Broome.
'Lack of consistency' in care mirrored boy's life
Ms Linton highlighted missed opportunities that could have helped the boy cope with his break-up, including an instance in 2014 when he dropped off the department's radar after choosing to disengage with mental health help.
Another missed opportunity was when there was a chance for him to get properly diagnosed at Princess Margaret Hospital in Perth.
Ms Linton said a major barrier that existed for Child J appeared to be him living in the Kimberley.
It was identified at the inquest that the Kimberley continued to be an exceptionally difficult place to work for child protection workers, particularly for those who often began straight out of university.
"The pressures of the job, and staff shortages, also contributed to high staff turnover, although there were many and varied reasons why staff did not always remain long term in the department's Kimberley office," Ms Linton wrote.
In the days before his death, Child J was assigned a case worker who had only recently graduated from university and taken on her first role in the Kimberley.
She later left the department after being placed on stress leave.
In her findings, Ms Linton highlighted the independent report of child and adolescent psychiatrist Nadine Caunt who had been tasked with independently reviewing Child J's case.
"Dr Caunt noted that, given the very limited services and resources that were available in the region at the time, she felt the people involved in his care did the best that they could have done," the findings read.
"While there were a number of missed opportunities to assess him more closely and try to identify the root of why he was struggling to manage his behaviours and emotions, there was still of lot of engagement with Child J by the department and health workers, marred primarily by the lack of continuity of his care.
Ms Linton said it was clear the lack of consistency in Child J's care was reflected in the lack of consistency in his life, and he found it hard to deal with feelings of abandonment due to ongoing trauma with his family.
He spent his life searching for meaningful relationships, and when he met his girlfriend, Ms Linton said, it was likely he had considered it an important connection in his life.
And when they split, he was unable to deal with the separation and regulate emotions of hopelessness and sadness.
His body was found with a photograph of his girlfriend.
Coroner urges quick action
Ms Linton noted the boy's case was not exceptional.
"The reasons why young Aboriginal people choose to take their lives are complex and multi-faceted, and they have been explored in other forums at a level much deeper than I am able to go in this inquest," she wrote.
"The WA government has indicated its commitment to implementing changes that will hopefully not only change the future for the coming generations of young Aboriginal and Torres Strait Islander children in this state, but also help those who are currently facing the many challenges that Child J experienced.
"For that reason, the government must act quickly if we are to make meaningful efforts to try to save the current generation."
