Description
RECORD OF INVESTIGATION INTO DEATHRef: 30/17
I, Sarah Helen Linton, Coroner, having investigated the death of HLS
with an inquest held at the Broome Courthouse, 8 Hamersley
Street, Broome on 7 – 10 August 2017 find that the identity of the
deceased person was HLS and that death occurred between 13 and
14 March 2013 at La Djadarr Bay, Dampier Peninsula, in
circumstances consistent with immersion in a young man with
traumatic amputation of the left foot and multiple soft tissue
injuries.
Page 20/41: Inquest into the death of HLS (6006/2013) 21
Expert Opinion of Dr Raewyn Mutch
108. Dr Mutch noted in her report that HLS’ life was “replete with events which
commonly assault young people when they have not been afforded a
diagnosis of FASD,” despite the fact that HLS had been diagnosed with FASD
from a very early age.(137) In Dr Mutch’s opinion, HLS was “consistently
managed in a way which indicated that the implications of that diagnosis
were not understood by the educational, health, child protection and judicial services he encountered.”(138) Dr Mutch referred to HLS’ innate vulnerability
arising from his FASD and associated impaired cognitive function, which in
the context of various negative experiences he had encountered throughout
his life, had the effect of exposing him to complex trauma.139
109. Much of this complex trauma occurred before HLS came into the care of the
Department, so it cannot translate into an adverse comment against DCP.
However, it was the legacy of that trauma that DCP had to face in dealing
with HLS’ increasingly complex care needs.
| Period | 2013 |
|---|---|
| Work for | The Coroner's Court of Western Australia, Australia |