WARNING: Aboriginal readers are advised this article contains details that may be distressing and information about people who have died.
Coronial inquest documents are usually grim, but this one was unforgettably tragic.
It detailed the lives of 13 children and young people who died by suicide in one of the most remote corners of the country.
There were the sisters, aged 10 and 13, who killed themselves just a couple of years apart. One had left a suicide note in her bedroom saying, "I love all of you and miss you."
There was the 12-year-old girl who died in a park after months of drinking and smoking weed and repeatedly threatening self-harm.
And the 16-year-old boy who, less than a year before he took his own life, revealed he'd been sexually assaulted by three men in his bedroom.
He said he had told his parents what had happened, but they were too drunk to understand.
Another teenager — none were named due to their young ages — had been found dead at an oval in Broome. He'd been living in a car park.
"His short life of 17 years was one of complete and utter despair," the coroner's report stated.
"From the moment he was born his life was largely one of struggles, pain, sorrow and neglect."
For months, coroner Ros Fogliani catalogued the lives of these lost children. After more than a year of emotional hearings and tearful testimony, she published 367 pages of findings.
"The deaths are profoundly tragic, individually and collectively," she concluded.
"The tragic individual events were shaped by the crushing effects of intergenerational trauma and poverty … that generated multiple and prolonged exposures to traumatic events for these children and young persons."
The process triggered promises of change to ensure Western Australia could buffer children from harm when parents or carers were incapable or unwilling to do so.
Five years on, has anything changed?
Gruelling evidence
The inquest examined the deaths of 13 Aboriginal people aged from 10 to 23. They died within a four-year period in the Kimberley region of northern Western Australia, which has one of the highest suicide rates in the world.
Their stories highlighted the challenges facing countless Australian children impacted by poverty, neglect, and a disconnect from social services.
In the early stages of the inquest, traumatised residents of a bush community told the ABC of the quiet afternoon when the 10-year-old girl took her own life.
"I heard this terrible screaming and I could see everybody running over to that house," a neighbour recalled.
"They were crying to just 'help her, help her'."
He said local children saw the girl's lifeless body before they could be shepherded away.
"It was the biggest mob of kids, of all different ages. They were just screaming and crying."
'Common threads' link deaths
Each of the young lives examined by Ms Fogliani were different and distinct, but patterns emerged.
"Common threads include numerous health issues as they grew up, home environments prone to alcohol abuse and domestic violence, frequent moves between households … poor attendance at school, below-average academic results, and a reluctance to seek the assistance of mental health services," she wrote.
The court heard evidence that six of the 13 young people had likely suffered sexual abuse, although no-one had ever been charged.
The level of care provided by parents and extended family was treated delicately, out of respect for the grieving relatives.
But there was evidence of carers too intoxicated to provide consistent care, and households too racked by domestic violence to be safe.
There were examples of families rejecting offers of parenting support, and young people not showing up for scheduled psychology appointments.
The process highlighted the fraught question of how and when the state should intervene in the welfare of children, especially in the context of governments trying to reduce the number of Aboriginal kids being taken into state care.
Ms Fogliani made a total of 42 recommendations, mainly around mental health services, housing, alcohol abuse, and culturally appropriate service provision.
But five years on, young Aboriginal leaders like Tonii Wajayi Skeen say kids are still "slipping through the cracks".
She says the prevalence of self-harm and suicide will continue until the fundamentals are addressed.
"Kimberley kids are resilient, but they're being exposed to more than they should be, and a lot of the time they're not learning coping mechanisms," Ms Skeen says.
"How do you wake up in the midst of disadvantage and still dream about what's in the future, and find a way to work around problems?
"People talk about intergenerational trauma like it's a fuzzy thing, but it's real – even in families that love each other, sometimes that love isn't shown or passed down – and every child yearns for that love."
The recommendations
Following the inquest, WA's now-Premier Roger Cook promised a "comprehensive" response, and annual updates on the implementation of the 42 recommendations.
This has not occurred — the latest update was published in September 2021.
In short, many of the recommendations have been implemented but some have not.
The WA government has delivered on a banned-drinkers register, the expansion of safe, short-term accommodation options for transient families, and initiatives to improve engagement with education and health services.
Innovative programs such as cultural healing are being trialled, and Aboriginal health organisations are delivering education and awareness campaigns on a scale not seen before.
But some commitments have not been honoured.
For example, five years ago the WA government allocated $9.2 million to create a specialist youth drug and alcohol service. Some of the money has been spent on consultants, but it's so far not been established.
Nor is there fetal alcohol spectrum disorder (FASD) screening for all children entering the child protection system, or Kimberley-wide liquor restrictions, despite the inquest hearing evidence that three-quarters of domestic violence incidents involved intoxication.
There is no up-to-date data available to show how youth suicide rates have tracked in the Kimberley since the inquest.
But national data shows the number of children aged 14 and under taking their own lives has increased over the past decade, reaching a record high in 2021.
'No-one wants to bury their child'
The WA Commissioner for Children and Young People, Jacqueline McGowan-Jones, says she believes there has been progress in the wake of the inquest, but changes are not being made urgently enough.
"I think we need to move faster," she told the ABC.
"The government has a 10-year implementation plan, but sometimes I don't think we realise that means we could lose hundreds of lives in that time."
Ms McGowan-Jones knows firsthand how high the stakes are.
She has Arrente and Warumungu heritage and has lost family members to suicide.
"When you lose a young person to suicide in your family there is trauma, grief, self-blame, blame of others — wondering every day what could you have done differently and how many more family members you will lose," she said.
"We need to keep in mind that our kids don't tend to ring Lifeline or Kids Helpline, and if they do they might be on hold for a very long period of time.
"Our kids have got trauma, and we need to be responsive and find the right programs and supports for kids to access, and that needs to be a priority.
"No-one wants to bury their child; that is not the natural order of things."
'What are they afraid of?'
Aboriginal community leaders say the most frustrating aspect is the government's promise to create a long-term governance structure to involve Aboriginal community leaders in decision-making.
"In 2021 they approached us to set up a partnership agreement, so we could work together to prioritise all the recommendations from these suicide reports and get them in place," said Kununurra-based Des Hill.
"But more than two years on, it's been very slow progress, very frustrating.
"It'll get to the point where we may as well just pick up these reports and throw them in the bin. It feels like they're mucking us around and we might all be wasting our time."
It's a piercing criticism at a time when governments around Australia are scrambling to find ways to "Close the Gap".
Mr Hill co-chairs the Kimberley-wide Aboriginal Regional Governance Group (ARGG), which is the primary point of contact for the government.
"Sometimes I think — what are they afraid of? Are they afraid to actually do their job because they're going to do themselves out of a job?" he asked.
"It's disturbing that it's not the old people we're losing, it's young people who are dying.
"You'll see a new grave, the mound of dirt, and you find out that it's a teenager — that breaks your heart."
A new way?
ARGG co-chair Jenny Bedford says the welfare of children needs to be front and centre of policy discussions.
"This is really high stakes," she reflects.
"We're deeply distressed and concerned about how suicide and self-harm is impacting our young people."
She says the partnership agreement is the kind of tangible structural change that could connect the good intentions of government with what's needed on the ground.
"We're just asking — respectfully — please can we find a way for government to do things a bit differently because otherwise things are not going to change," she said.
The WA government did not respond to questions about the delays in delivering the promised joint partnership.
Nor did it explain why promised annual updates on the coroner's recommendations have not been delivered.
In a statement, it outlined ongoing funding commitments and said it was "committed to continuing to work in partnership with Aboriginal community-controlled organisations".
'The Aboriginal industry'
Tonii Wajayi Skeen advocates for youth services on several government consultation committees.
She says increased accountability is needed to ensure organisations are delivering outcomes.
"We've got a big industry here in the Kimberley, and sometimes it feels like it's based on the suffering and the misery of Aboriginal people," she reflects.
"We have a lot of money coming in — we can't keep crying for more money — but we need to do things differently by involving young people in terms of how decisions are being made.
"What I see are things that are working, or have the potential to work, but are not getting appropriately resourced."
One example is the Yiriman project, which runs on-country camps for at-risk children.
The 2019 coroner's report recommended the project be funded to expand and ensure long-term viability.
It has since been funded to complete a business case but continues to operate on minimal resourcing in the Fitzroy Valley.
For now, the questions posed in the coroner's opening address remain as relevant as ever:
"Dozens of reports, thousands of pages and hundreds of recommendations, yet the problem remains — too many Aboriginal children and young people are taking their lives.
"Why has it got to this?
"Is it now time to accept that a radically different approach needs to be taken that prioritises the safety and protection of vulnerable children above everything else?
"If ever there was a time for change, it is now."