Finding into death of Taylor Page Janssen

IN THE CORONERS COURT OF VICTORIA AT GEELONG

Court Reference: COR 2009 001767

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Inquest into the Death of: TAYLOR PAGE JANSSEN

Delivered On:

Delivered At:

Hearing Dates: Findings of: Representation:

Police Coronial Support Unit Assisting the Coroner:

y

28 November 2014

Coroners Court of Victoria Railway Terrace, Geelong Victoria 3220

18 - 20 November 2013

JUDGE IAN L GRAY, STATE CORONER

Ms E Gardner appeared on behalf of the Department of Education and Early Childhood Development

Senior Sergeant Jen Brumby.

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I, JUDGE IAN L GRAY, State Coroner, having investigated the death of TAYLOR PAGE

JANSSEN

AND having held an inquest in relation to this death on 18 - 20 November 2013 at GEELONG find that the identity of the deceased was TAYLOR PAGE JANSSEN born on 18 March 1993 and the death occurred on 28 March 2009 at Geelong Hospital, Bellerine Street, Geelong Victoria 3220 from: 1(a) MULTISYSTEM ORGAN FAILURE AND CEREBRAL HYPOXIA

1(b) HANGING.

in the following circumstances:

INTRODUCTION AND PURPOSE

1. This inquest examined the circumstances and contributing factors relating to the death of Taylor Janssen. Before I make my findings on these circumstances and factors, I wish to convey my sincere condolences to Taylor’s parents, Mr Steven and Ms Helen Janssen and her family and friends, The unexpected death of a young person is devastating for parents, family and friends, and my purpose in holding this inquest was to explore whether any lessons can be learnt, which

might prevent similar deaths in the future.

2. This prevention role is one of two parallel fimctions of the modern coronial system. The first involves the findings that I must make under the Coroners Act 2008 (Vic), which requires, if possible, that I find the:

• identity of the person who has died

• cause of death (and for our purposes this usually refers to the medical cause of the death)

and

• circumstances surrounding the death.

3. Itis the investigation J am permitted to conduct surrounding the circumstances of a death that gives rise to my ability to consider broader issues of public health and safety. These

considerations form the second parallel purpose of a coronial investigation into a death. This

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purpose has been enshrined in the Preamble of the Coroners Act 2008 (Vic), which sets out that

the role of the coroner should be:

• to contribute to the reduction of the number of preventable deaths and

• promote public health and safety and the administration of justice.

RELEVANT HISTORICAL FACTS

4, Taylor was a 16-year-old female and was the oldest of three children to Steven and Helen

Janssen. She had no significant medical or mental health history.

5. Taylor attended the Quamby campus of Western Heights Secondary College (WHSC). In around 2007, she began a relationship with fellow. WHSC student, Zachary (Zac) Harvey. Over the next two and a half years, Zac was welcomed into the Janssen family. He would regularly stay at their home overnight and attended family holidays. Steven and Helen Janssen did hold concerns towards the end of their relationship that they were spending a significant amount of

time together to the detriment to other friendships of both of them.’

CIRCUMSTANCES OF THE INCIDENT

6. On the evening of Sunday 1 March 2009, a series of text messages were exchanged between Zac and Taylor discussing the dissolution of their relationship. When Zac attended school the next day, he further informed Taylor that he no longer wished to continue their relationship. No reason was given to Taylor as to why Zac no longer wanted to see her, and this caused her some angst and resulted in intense arguments with Zac.” While not the type of boy to talk about his

problems, Zac seemed calm about the situation?

7, On6 March 2009, Zac was in class with Taylor when an argument developed between them in relation to Taylor sitting next to another boy. Zac left school immediately following this argument and returned home where he recounted the incident at school to his mother. It was approximately 11:15am when Zac returned home from school. At approximately 12:15pm, Ms

Harvey left the house and Zac remained at home.

8. Upon returning home at approximately 2:50pm, Ms Harvey found Zac hanging from a nylon

rope. She called 000 and police and paramedics attended, but Zac was deceased. A text message

Statement of Mr Steven Janssen dated 1 May 2009, page 1.

? Statement of a witness dated 11 May 2009, page 1.

Statement of Ms Margaret Harvey dated 11 April 2009, page 1.

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to a friend was found contained on his phone that read, “tell Taylor sorry”. No other written note was located indicating the reasons for Zac’s actions, and there were was no evidence to

suggest another party was involved.

9, At around 4.00pm on 6 March, Taylor was informed by Zac’s mother that he was deceased.

Taylor telephoned her friend, who immediately went to visit her and stayed at her home for the night. She repeatedly asked Taylor whether she was contemplating taking her life, and Taylor

responded that she “just wanted to be with Zac”!

10. Taylor’s friend telephoned Taylor’s mother after leaving the house the next day, and reported her concerns for Taylor’s welfare. Over the following two weeks, she would regularly try to call and send text messages to Taylor, to which she would respond on some occasions. She

offered to visit her but Taylor declined.>

11. Taylor was withdrawn and refused to eat in the days following Zac’s death. She assisted Zac’s parents with funeral arrangements, and became more tense and withdrawn in the days before

the funeral. She attended and was visibly upset. Taylor’s parents observed her closely.®

12. Taylor’s birthday was on 18 March 2009, the day after Zac’s funeral. She went out for dinner with her friend that evening and told her that she had searched the internet for information on hanging oneself. became upset and concerned, but Taylor reassured her that she had only done

so to understand how Zac had died and whether he had suffered at all.’

13. Taylor returned to school about two weeks after Zac’s death, but found it difficult to cope, so her parents told her that she could stay home until she felt ready to return. Taylor did not attend

school again before her death.

14. On 27 March 2009 at around 12,00pm, Mr Janssen arrived home at around midday. He could not find Taylor inside, so went out to the back of the house and found her hanging in the garage. Mr Janssen telephoned a friend for assistance, and he and his wife arrived a short time later and called 000. They also assisted to cut the rope and let Taylor down. Mr Janssen’s

friends performed CPR until paramedics attended and continued resuscitative efforts.

• Statement of a witness dated 11 May 2009, page 2.

• hid.

5 Statement of Mr Steven Janssen dated 1 May 2009, page 2.

7 Statement of a witness dated 11 May 2009, page 3.

5 Ibid page 4.

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15. Taylor was transported by ambulance to the Geelong Hospital, and further resuscitative efforts were administered. Unfortunately, Taylor’s condition was not survivable, and she died in

hospital on 28 March 2009 at around 6.00pm.

16. A detailed typed note was found near Taylor addressed to her family and indicating the reasons

for her actions. The note evidenced a significant degree of planning.

17. Taylor’s death was one of three deaths heard as part of the inquest, the relevant factors for which will be the subject of a separate finding. However, any overlapping circumstances and

factors will be covered in all findings.

FINDINGS AS TO UNCONTENTIOUS MATTERS

18. In relation to Taylor’s death, most of the matters I am required to ascertain, if possible, were uncontentious from the outset. Her identity, the date, place and medical cause of her death were never at issue. I find, as a matter of formality, that Taylor Page Janssen, born on 18 March 1993, aged 16, died at the Geelong Hospital, Bellerine Street, Geelong Victoria 3220 on 28 March 2009.

THE MEDICAL CAUSE OF DEATH

19, Nor was the medical cause of death controversial. On 30 March 2009, an external examination of Taylor’s body was performed by Senior Forensic Pathologist Dr Malcolm Dodd of the Victorian Institute of Forensic Medicine (VIFM), who also reviewed the circumstances as reported by the police and post-mortem CT scanning of the whole body (PMCT). Dr Dodd noted the presence of a well defined area of intradermal bruising around the neck, in keeping with the application of a ligature. Dr Dodd did not find any evidence of offensive or defensive type injury, and formulated the medical cause of Taylor’s death as multisystem organ failure and cerebral hypoxia secondary to hanging. Toxicological analysis of ante mortem blood did

not reveal the presence of ethanol (alcohol) or any other drugs or poisons.

FURTHER INVESTIGATION

20. The Coroner’s Investigator, Leading Senior Constable Shane Lorimer prepared a brief of evidence comprising a series of statements from Taylor’s parents and from a friend of both Zac

and Taylor. This also included an appendix of photographs of the incident scene.

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21, During the investigation of these deaths, it came to the attention of the Coroners Court of Victoria that seven persons’ aged 18 years and under residing in the City of Greater Geelong had suicided during 2009, Zac and two others prior to Taylor and three after. This was compared to one in 2008 and one in 2007. It is also significant to note that there were no suicides amongst persons aged 18 years and under in 2010, one in 2011, one in 2012 and two in 2013!°, This retrospective examination of suicides amongst persons aged 18 years and under showed that during 2009, the City of Greater Geelong experienced a suicide eluster!!, as defined by the Centres for Disease Control and Prevention. On this basis, assistance was sought from the Coroners Prevention Unit (CPU) to review the evidence provided by Victoria Police to identify and examine the presence and patterns of contributing factors to these deaths to

inform recommendations for prevention.

22, The CPU review identified four factors that warranted further examination and / or input from

external organisations:

a. the presence and association between exposure to suicidal behaviour in the social network

and an individual’s risk of suicide.

b, media treatment of youth suicide, including:

i. the potential for media coverage of youth suicides to trigger further suicides among

vulnerable and impulsive young people; and

ii. the potentially intrusive and distressing nature of reporters’ behaviour towards a

grieving family whose child has suicided.

c, the presence and role of bullying and cyber-bullying on youth suicide.

d. the local post-vention response by:

i, the Department of Education and Early Childhood Development (DEECD), including Western Heights Secondary College, and

Court Reference Numbers: 20090405; 20090665; 20091426; 20091767; 20093500; 20093966; 20094922.

‘0 During this seven year period, the City of Greater Geelong experienced the highest frequency of suicides of young people aged 13-18 years in the State of Victoria. When the population of 13-18 year olds was accounted for, the City of Greater Geelong ranked sixth in the state for females (8.3 suicides per 100,000 population) and equal eighteenth in the state for males (6.7 suicides per 100,000 population).

"| 4 group of suicides or acts of deliberate self-harm that occur closer together in space and time than would normally be expected on the basis of statistical prediction and/or community expectation (Centres for Disease Control, 1994).

2 The Coroners Prevention Unit is a specialist service for coroners established to strengthen their prevention role and provide them with professional assistance on issues pertaining to public health and safety.

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24,

ii, Barwon Health.

The CPU coordinated the identification of and engagement with appropriate organisations and individuals who provided written submissions on the four factors. On the issue of media treatment of youth suicide I received information from the Australian Press Council (APC) and the Hunter Institute of Mental Health (HIMH). On the issue of bullying and cyber-bullying I received information from the Alannah and Madeline Foundation. On the issue of the postvention response, I received information from Barwon Health, the Barwon Adolescent

Taskforce and the DEECD.“4

Whilst the inquest examined the above factors, it should be noted that not all of the issues were

relevant to all three cases.

FOCUS OF THE CORONIAL INVESTIGATION AND INQUEST

In common with many other coronial investigations, the primary focus of the coronial investigation and inquest into Taylor’s death was on the circumstances in which she died. The

inquest into Taylor’s death was held jointly with inquests into two other deaths, being Zac

Harvey and Chanelle Rae. The inquest examined the circumstances surrounding each of the

three young people, Zac Harvey, Taylor Janssen and Chanelle Rae, in the lead up to and

immediately proximate to death.

The inquest was held jointly because the deaths of each of the young people were linked as they were all young adolescents who took their own lives at their homes, were all students at WHSC at the time of their deaths, and their deaths all occurred in the same year. Both Zac and Taylor’s

deaths are also linked as they were in a relationship until shortly before their deaths.

Exposure to Suicide as a Risk Factor

27. In terms of exposure through social networks, there was evidence that some of the young

people had attended or were current students of WHSC and were therefore known to each other.

Lasked the CPU to provide advice on the association between exposure to suicidal behaviour in

e social network and an individual’s suicidal behaviour.

th 1 network and dividual’ dal beh:

'S The Australian Press Council is the peak organisation for promoting good standards of media practice as well as the principal body with responsibility for responding to complaints about Australian newspapers.

4 Note that usefull information was also received from a large number of other organisations to inform this investigation.

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28. The CPU reviewed 54 original research studies that were conducted between 1967 and 2009 based on suicide behaviour’ and included an examination of exposure to suicidal behaviour in the social network.'® The CPU concluded that although no study reported evidence of a direct causal relationship between exposure to suicidal behaviour of a person in the social network and suicide, an association was reported in the majority of studies. The CPU advised that a risk management approach should be taken to post-vention responses to persons potentially affected

by suicidal behaviours of individuals in their social network.

29, Zac and Taylor’s deaths occurred following the deaths, from suicide, of two other Geelong youths earlier in 2009. There was no evidence that either Zac or Taylor were aware that these deaths had occurred, were acquainted with either person or, more importantly, were adversely impacted. However, Taylor was observed by her family and friends to be significantly impacted by Zac’s suicide. In fact Taylor conveyed to her family in a written note to them that she could not live without Zac in her life and her desire to be at peace with him. Despite Mr and Ms Janssen’s vigilant monitoring of Taylor given their concern for her welfare, there was evidence

that Taylor’s actions were well planned an opportunistic.

Exposure to Suicide via the Media as a Risk Factor

30. Zac’s death, and the subsequent death of Taylor, were widely reported in the two local newspapers. As such, there was a heightened awareness of the deaths in the community. This heightened awareness promoted through the media raised concerns as there is research evidence that aspects of mass media reporting of suicide is associated with increased subsequent suicidal behaviour at a population level.!” This issue is explored in further detail in my findings in to the death of Chanelle Rae.

Cyber bullying concerns and online communication

31. Judge Alistair Nicholson, chair of the National Centre Against Bullying and member of the

advisory board of the Alannah and Madeline Foundation, gave evidence at inquest. Both the

15 Suicide behaviour was defined in accordance with the Centre for Disease Control and Prevention as: suicide, suicide attempt or suicidal ideation.

‘6 Social network was defined as: a formal or informal linkage, association, or network of individuals or groups that share common interests, contacts, knowledge or resources.

'7-Tousignant M, Mishara BL, Caillaud A, Fortin V, St-Laurent D. The impact of media coverage of the suicide of a well-known Quebec reporter: the case of Gaétan Girouard. Social Science & Medicine 2005;60(9):1919-1926; Pirkis J, Blood RW. Suicide and the media: Part I. Reportage in nonfictional media. Crisis. 2001;22:146-154; Sisask M, Varnik A. Media roles in suicide prevention: a systematic review. International Journal of Environmental Research and Public Health 2012;9(1):123-138.

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33,

34,

Foundation and the Centre have a particular interest in student and children’s wellbeing,

including the issues of bullying and protection of children when online.

Judge Nicholson stated that the Foundation ‘see/s] bullying and cyber bullying as ... two sides of the one coin’.'® His Honour discussed law reform in New Zealand to the effect that bullying behaviour attracts criminal sanctions, but expressed a view that any criminal proceeding should

be a matter of last resort, especially where children are concerned.

His Honour also addressed concerns about children accessing content online that might be harmful, particularly in the context of Taylor Janssen’s death and evidence that she had accessed websites that contained information to assist her to take her own life. His Honour provided a copy of a letter from the Federal Parliamentary Secretary to the Minister or Communications regarding online safety,’ in response to queries from the Foundation. The Government advised of a range of policies in place to help protect children online. These

include:

• the establishment of a Children’s e-Safety Commissioner to take a national leadership role

in online safety for children

• implementing a complaints system for the fast removal of material from social media sites

that is harmful or distressing for children

• investigating options for a simplified cyber bullying offence

• improving safety options on smart phones and other devices including optional software to

help protect children from inappropriate content ~

• establishing advice and guidelines for parents about appropriateness of media items for children

• improved support for schools for online safety programs

• funding to support research and information campaigns on online safety

• consultation with industry and community organisations.

I support any policy development and ongoing consultation aimed at increasing online safety for young people, whilst noting His Honour’s evidence about the primary role that parents and

other supports for young people in ensuring open communication about safety online, and

'8 Inquest transcript page 151.

19 Rxhibit 12, letter to The Hon Alastair Nicholson from Paul Fletcher MP dated 14 November 2013.

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proper supervision of children’s activities online. J understand that the federal government will

legislate to create the new Children’s e-Safety Commissioner by the end of the year.

Post-vention Response by the Department of Education and Early Childhood Development

35. The Department of Education and Early Childhood Development (DEECD) provided detailed submissions specifying its programs and available resources in relation to bullying, cyber bullying, suicide, suicide prevention and mental illness. The'submissions detailed a range of

programs, aimed at different age groups and levels as appropriate.

36. DEECD explained in its submission that each Victorian Government School operates in an environment of devolved decision-making, and that it is the responsibility of each school Principal and School Council to make decisions about individual programs and resources that are most appropriate for the needs of their students.2° At inquest, Ms Kris Arcaro on behalf of the department, explained that there are no mandatory programs in schools in relation to the above matters, but that broadly, the DEECD states that schools must ensure a safe, supportive and respectful environment. In achieving this, schools can then choose which particular programs they implement, including programs that are not developed by DEECD.”! However, in practice, schools would usually look to the DEECD for advice on sound, evidence-based

programs.”

37. Ms Arcaro emphasised that the work of the department focuses on prevention, health promotion and early intervention, and that most of its resources hold this focus. She also provided details at inquest as to the key focus of the present government on building resilience in schools, and.

programs that support this.2? Ms Arcaro also explained that, in addition to providing schools with programs, the DEECD also provides direct support to school and young people, via its team of psychologists, social workers and youth workers, and that this resource is available to

all schools.

38. Lam satisfied, from the evidence of the DEECD, that at the department level, there are sufficient ongoing support services for staff, students and their families through various means.

Ms Arcaro stated that the position of the DEECD is that schools should also work in partnership

2° Submissions of DEECD dated 11 November 2013, Exhibit 8, page 1.

21 Inquest transcript page 88.

? Thid page 89.

33 Thid pages 94-5.

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with community agencies that are in their local government areas in order to derive maximum

benefit from the available supports.

I asked Ms Arcaro whether resources were available for students to access support privately, should they not wish to discuss a matter with teachers, other school support staff or anyone else.

Ms Arcaro referred to the Headspace school support service, which offers an e-counselling service that young people could access directly. The Headspace initiative had not been

implemented in 2009 and was not therefore available at the time of the three deaths.”*

The DEECD also made submissions regarding support and resources available at WHSC specifically at the time of Taylor and the other students’ deaths. Ms Elizabeth Jones of the

DEECD gave evidence at inquest on this issue.

In 2009, WHSC had approximately 1200 students spread across two campuses. Zac and Taylor were students at the ‘Quamby’ campus, and Chanelle was a student at the ‘Minerva Road’ campus. The school’s student support services officers included the college chaplain, student wellbeing coordinator, a health promotion nurse and student support service officers in the Barwon South Western regional office. The school also had relationships with, and access to

external support services,”

Preventative strategies available at the WHSC at the time of the three deaths in 2009 included:

• targeted health and wellbeing days

• mental health promotion

• development of a code of learning behaviours

• arequirement that all students complete work and attain accreditation in the school’s

‘Acceptable Use of Technology’ policy

• staff training in the ‘Habits of Mind’ framework to integrate into student learning

• parent forums on challenging behaviour, adolescence and safe use of technology

• all students being assigned a home group and teacher mentor

• peer monitoring

24 Tnquest transcript pages 96-7.

5 Submissions of DEECD dated 11 November 2013, Exhibit 8, page 30.

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• promoting student participation and engagement through the school’s Student Action team

format

• restorative practices framework to respond to incidents of concern

• telationships with local police who would present to groups of students, and individual

students after an incident of concern,”

In addition, WHSC was involved in mental health promotion and suicide prevention strategies

that were available in the Geelong community.”’

DEECD submitted that the extensive media reporting on the three student deaths added to the trauma experienced by the community, adversely impacted the community, impeded recovery

and added further complexity to managing the deaths.”®

Following the deaths, DEECD submitted that WHSC closely monitored all students to identify who might be at risk and in need of further support and assistance, and that there were up to 78 students receiving necessary support at one time. The health and wellbeing of WHSC staff was also being closely monitored, with extra staff being provided from neighbouring schools as well

as relief staff, and a community liaison officer was engaged.”

The school identified Taylor Janssen as being particularly at risk following Zac’s death and maintained regular contact with her family. The school also corresponded regularly with families after each death informing them of the death and providing information about care and support available to students, as well as community services for families. The school considered students that might be at risk and provided targeted intervention, follow up and monitoring given concerns about contagion.” WHSC provided additional ongoing support and monitoring following Taylor Janssen and Chanelle Rae’s deaths, and following the suicide deaths of a student at Geelong College, Taylah Mahon, and a student at St Ignatius College in Drysdale, Stephanie Winberg.”!

26 Submissions of DERCD dated 11 November 2013,Exhibit 8, pages 30-31.

21 Thid page 32.

28 Ibid page 33.

2 Thid pages 34-5.

3° Ibid pages 36-7.

3! Ibid pages 35-43.

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49,

At inquest, Ms Jones elaborated on the department’s submission that the extensive media reporting of the deaths adversely affected the students’ recovery. She stated that the media attention that increased following the death of Chanelle Rae, the number of students potentially at risk and requiring support also increased. The school was required to seek additional

psychological and counselling resources, and staff were also adversely impacted.*?

At inquest, Ms Jones also elaborated on DEECD submissions to the effect that it had been identified that some students had discussed or planned suicide, and that a pact of sorts had been arranged. Ms Jones stated that the work of the department’s student support services network

identified this and provided intensive support to the young people and their families.*

Ms Jones also addressed my question about the availability of a support service for students to access privately, prior to the introduction of the Headspace initiative. She explained that the school had a tutor system in place where a teacher identified as a key contact person fora student, and that information was provided to students routinely about other support services

available to them outside the school.

Ms Jones testified at inquest that, by 2009, there was a large body of research around resilience, and that schools put supports and programs in place with this focus. In the case of WHSC, Ms Jones explained that the tutor group process aligned with the resilience model, by ensuring that

students had an appropriate adult they could tum to for support."

Ms Jones addressed the department’s ‘Guidelines to assist in responding to attempted suicide or suicide by a student’, which were not in place in 2009. Ms Jones testified that the response of WHSC was very consistent with the guidelines,®* and stated that WHSC was using all relevant and available policies and resources available to them in 2009, particularly the key document at

the time regarding ‘managing school emergencies’.*°

I accept Ms Jones’ evidence on each of these matters. I also accept that the WHSC was appropriately utilising ‘relevant and available policies and resources available to them’ at the

time.

» Inquest transcript page 105.

3 Tbid page 108.

• Thid page 120.

3 Thid page 121.

8 Ibid.

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Post-vention Response by Barwon Health

53. Mr Chris Scanlon from Barwon Health Mental Health Service provided the Court with a helpful submission on: how health services were notified and responded to the youth suicides in Geelong; the impact they had on the local health system and the community; and any learning from the Geelong experience that may be translatable to other settings.’’ He also provided a best practice guideline titled Talking about suicide with young people developed by the

Victorian Mental health Promotion Officers.

54. Mr Scanlon advised that the DEECD notified the Barwon Health Mental Health Service of the suicide incidents, who also convened a meeting between relevant local services to determine and resource an appropriate response”®, The Victorian Department of Health resourced Barwon Health and Headspace Barwon for both short and long-term strategies, the implementation of

which was overseen by a coordination committee.

55. In the short term, enhanced clinical services (mental health and suicide risk assessments and additional support consultations) were provided as a priority following an increased demand for assistance. Liaison with media outlets was also instigated following concerns about reporting practices that were outside the recommended guidelines that were creating additional angst in

the community.

56. Education and training, which included Youth Mental Health First Aid (YMHFA) and Applied Suicide Intervention Skills Training (ASIST), was provided for school and school support staff.

Mr Scanlon reported that this was beneficial as a longer-term strategy to strengthen the service

system, with over 400 school personnel trained in 2011-2013.

57. Mr Scanlon reported that the 2009 youth suicides in Geelong had a significant impact on family, friends, schools, health services and the community. Since these events, Mr Scanlon believes that there has been a greater focus on coordination of services. He concluded his evidence with the comment that an evidence-based and timely response to events such as these will inform prevention and post-vention strategies. I accept Mr Scanlon’s evidence on these matters. I agree with him on the importance of timely, coordinated local responses to events

such as these.

37 Inquest transcript page 121.

8 Exhibit 13, page 1.

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Barwon Adolescent Task Force

A submission was also provided by a representative from the Barwon Adolescent Task Force. It

contained a number of observations and suggestions including:

• the need to engage parents and caregivers to participate in generic education sessions from their child’s early years (8-12 years) onwards to empower them to promote resilience and

identify early warning signs

• introduce evaluations of resilience programs delivered in primary schools

• • develop interventions focused on increasing protective factors for suicide, such as

connectedness to community, family and / or significant other adult outside the family

• audit of schools with staff that have received ASIST training.

Inote these and thank Barwon Adolescent Task Force for its contribution.

CONCLUSIONS

The suicide death of a loved one is an event that often leaves family, friends and the community with a great sense of loss and unanswered questions as to what happened and why. It can reverberate throughout a family for generations, and can impact upon both the memory of the

deceased, and his or her surviving family.

I accept and adopt the medical cause of death as identified by Dr Dodd and find that Taylor died from hanging in circumstances where I am satisfied that she intended to take her own life.

Taylor’s decision was triggered by the suicide of her recently former boyfriend Zac. There was no evidence of any other stressors in Taylor’s life that may have influenced her choice in the

course of action she ultimately adopted.

Finally I wish to acknowledge and thank the many individuals and organisations that provided information and their expertise to this investigation. In particular, the Department of Education and Early Childhood Development, the Australian Press Council, the Hunter Institute of Mental Health, the Alannah and Madeline Foundation, Barwon Health and the Barwon Adolescent

Task Force.

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COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:

62. In light of the evidence that Taylor was able to access information online that may have assisted her to take her own life, I heard evidence regarding a range of Federal Government policies in place to help protect children online, including the establishment of a new Children’s e-Safety Commissioner by the end of the year. I support and welcome this and other policy developments aimed at increasing online safety for young people. However, the importance of parental supervision, education and open communication about children’s activities online cannot be understated. In stating so, I acknowledge that it is very difficult to supervise children

whilst they are online, especially nowadays, where children might spend significant amounts of

time online on portable devices like smart phones and tablets, and time spent online is therefore

not confined to time spent at a computer at home or school.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s)

connected with the death:

1. The World Health Organization (WHO) has recognised suicide as an issue of global public health significant and that suicide prevention should be a priority for governments and policymakers.°” The WHO, of which Australia is a member state, places the responsibility for prevention in ministries for health and suggests that national plans of action be developed in

collaboration with relevant government and non-government agencies.“

2. In Australia, the Department of Health is the lead agency responsible for the National Suicide

Prevention Strategy, comprising four inter-related components:

• Living is for Everyone (LIFE) Framework“!

• National Suicide Prevention Strategy Action Framework”

®° World Health Organization. Preventing suicide: a global imperative. World Health Organization, Geneva. 2014.

*° Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. The Lancet. 360:1083-88,2002.

4 The LIFE framework sets the strategic policy framework for national action to prevent suicide, which includes a practical suite of resources. http://www.health.gov.aw/internet/main/Publishing.nsf/Content/mental-nsps.

” Developed by the DHA and the Australian Suicide Prevention Advisory Council (ASPAC) to inform national leadership in suicide prevention and policy. http://www. health.gov.au/internet/main/Publishing.nsf/Content/mentalnsps.

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• National Suicide Prevention Programme (NSPP)”

• Mechanisms to promote alignment with and enhance state and territory suicide prevention

activities.

3. While I accept that Departments of Health (in Victoria, the Victorian Department of Health), should ‘lead’ suicide prevention activities, this investigation has shown that other organisations at the local community level played a critical role in both the identification of and response to

suicide.

4. One key organisation at the local level is Victoria Police. While it could be argued that suicide prevention is not the primary role of Victoria Police, they do have a public safety function and are required to report and investigate deaths from suicide for coroners. This mandate brings them into frequent contact with the issue of suicide. Members of Victoria Police have sought to be proactive on this issue and frequently contact the Court regarding local concerns with suicide

they have identified.

5. Local health services also have frequent contact with persons experiencing a situational stressor or crisis event as part of their ongoing ill health and are therefore another important group involved in a local response. General practitioners and emergency departments are the front line

health services that assist in these circumstances.

6. In addition to Victoria Police and local health services, local governments have recently taken the lead in responding to another youth suicide cluster in Victoria. While this investigation is still ongoing by another coroner, I note that the City of Casey has a dedicated youth suicide prevention information page on their website, which includes a link to the Suicide Awareness Youth Focussed Tool Kid (SAYFT) website containing information for young people, professionals and parents on prevention, immediate assistance, post incident and training.“ The role of local government in suicide prevention has been previously recognised following a major inquiry into the nature and extent of suicide in Victoria in the late 1990s conducted by the Victorian Suicide Prevention Task Force. In their 1997 report, the need for the development of a

municipal plan with targets for improving social and emotional wellbeing was identified.* In

• An Australian Government suicide prevention funding program for community based projects and national investment for population health approaches and support for infrastructure and research.

http://www. health.gov.au/internet/main/Publishing.nsf/Content/mental-nsps.

“4 http://www.casey.vic.gov.au/youth/programs-services/support/youth-suicide.

*® Suicide Prevention Taskforce. Suicide Prevention Task Force Report. 1997. Page 116.

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addition, the University of Melbourne’s 2012 report titled Developing a community plan for preventing and responding to suicide clusters is a step-by-step guide for communities to develop and activate a response to suicide.** While the report focuses on suicide clusters, it

could have more general application.*”

7, In light of all of this information, there is an opportunity to reinvigorate suicide prevention

activity in Victoria. What appears to be lacking is:

• ongoing gathering of real time intelligence on the frequency and rate of suicide in local

communities

• exchange of intelligence and advice between local community organisations and the state

and national organisations responsible for suicide prevention

• anuanced understanding of the presence and combination of risk factors that might

influence suicidal activity amongst groups in the community

• aco-ordinated local response and recovery strategy in place that can be activated when

concerns are raised in the community about elevated levels of suicidal behaviour

8. Inthe absence of community level involvement and integration into a broader Victorian suicide prevention plan or strategy, it is difficult to fathom how suicide reductions will be achieved in the short or long term. Having said that, the development of detailed plans and strategies are a time consuming task and given the complexity of suicide, it may be some time before such a strategy could be developed and implemented. The recommendations contained in the 1997 Suicide Prevention Task Force Report, the evaluations that followed and the University of

Melbourne’s report may be applicable.

9. I therefore recommend that the Department of Health together with Victoria Police, the Municipal Association of Victoria, the Royal Australian College of General Practitioners and the Chief Psychiatrist undertake a review of these reports and develop a policy framework that

aligns, where appropriate, with the National Suicide Prevention Strategy.

I direct that a copy of this finding be provided to the following for their information: Mr Steven and Ms Helen Janssen, senior next of kin Department of Education and Early Childhood Development, c/o Ms E Gardner

“6 Lockley A, Williamson M, Robinson J, Cox G, Cheung YTD, Grant L, Pirkis J. Developing a community plan for preventing and responding to suicide clusters. Canberra, Commonwealth of Australia, 2012.

“’ Note that this resource was developed within the context of the Living Is For Everyone (LIFE) framework referred to above particularly Action Area 3: Improving community strength, resilience and capacity in suicide prevention.

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The Hon. David Davis MLC, Victorian Minister for Health

The Hon. Kim Wells, MP, Victorian Minister for Police and Emergency Services

The Hon. Mary Wooldridge, Victorian Minister for Mental Health

Mr Tim Bull, MP, Victorian Minister for Local Government

Dr Kevin Freele, Executive Director, Barwon Health

Mr Leigh Bartlett, Barwon Adolescent Task Force

Dr Jaelea Skehan, Director, Hunter Institute of Mental Health

Dr Derek Wilding, Executive Director, Australian Press Council

Ms Sandra Craig, National Centre Against Bullying, Alannah and Madeline Foundation The Geelong Advertiser, c/o KellyHazellQuill Lawyers

Leading Senior Constable Shane Lorimer, Coroner’s Investigator, Victoria Police.

I direct that a copy of this finding be provided to the following for. their response: Dr Pradeep Philip, Secretary, Department of Health Chief Commissioner Ken Lay APM, Chief Commissioner of Victoria Police Dr Mark Oakley Browne, Chief Psychiatrist Mr Rob Spence, Chief Executive Officer, Municipal Association of Victoria

Associate Professor Morton Rawlin, Chair Victoria Faculty, Royal Australian College of General Practitioners.

Signature:

Poe al

JUDGE IAN L GRAY STATE CORONER Date: 28 November 2014

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