By Violet Li
Parents of a South East teenager who died of a heroin overdose say their child was failed by state residential care services and inadequate autism therapeutic interventions, a coroner report has revealed.
State Coroner Simon McGregor delivered a detailed report on 28 January on the drug overdose death of an 18-year-old in state care in Cranbourne North.
Since he was 15, the teen was placed in several residential care homes after he had assaulted his father.
He had shown behavioural difficulties since the age of five, and diagnosed with high-functioning autism and associated ADHD. He started using illicit drugs at around 13.
The high-risk behaviours and illicit drug use continued as the teen moved into residential care.
The teen’s parents expressed concerns about their child’s exposure to a negative peer group while in residential care.
They observed that he engaged in criminal activities with his peer group, including stealing, carjacking, and assaults, and largely stopped attending school.
Coroner McGregor also found that the teen started ‘chroming’, overdosed on Xanax and alcohol, and self-harmed, requiring hospitalisation on a number of occasions.
The day before the tragedy, the teen asked his support worker to take him to Cranbourne North Woolworths, and was observed to “hide something in a white plastic bag behind his back” after he returned.
The mother told the court that children with complex disabilities should not be placed in group residential homes.
She also expressed concerns that the current therapeutic interventions to support children and families experiencing complex behaviours of concern are inadequate.
During the year in residential care, the teen was diagnosed with Pathological Demand Avoidance (PDA), a subtype of the autism spectrum disorder, and borderline intellectual function.
PDA is characterised by an intense resistance to demands, exceeding typical reluctance to follow requests or expectations, along with extreme efforts to evade social obligations.
The mother advocated strongly for increased recognition of PDA and the availability of appropriate therapeutic support.
PDA is currently not recognised as a standalone mental health condition in Australia. According to a review of the Coroners Prevention Unit (CPU), there are no specific evidence-based recommended treatments or management strategies for PDA. The subtype is not widely accepted in Australian psychiatry as a diagnosis requiring specific treatment.
The CPU observed that the teen’s early diagnosis of “high-functioning autism” might have led the parents to understandably feel that many of his challenges could not solely be accounted for by the autism spectrum disorder.
“The CPU was of the view that (the teen’s) ASD likely had a far greater functional impact than may have been initially understood, compounded by his borderline intellectual capabilities,” Coroner McGregor wrote.
“He may not have received the scaffolding and support he required, resulting in a cascade of behavioural challenges that he faced in his teenage years.
“This was further compounded by changes in the family unit, his co-occurring diagnoses of ADHD and borderline intellectual function, and the significant trauma often faced by young people in out-of-home care.”
CPU also concluded that the teen’s overdose death “does not appear to have been due to him residing in residential care, as the teen was already sourcing illicit substances while living with a parent”.
Coroner McGregor stated that coroners do not investigate aspects of care that have not contributed to a person’s death.
“Whilst I appreciate the time taken to detail these concerns and recommendations, the role of the coroner is limited. I am only empowered to examine matters that are proximate and causative, or contributory, to a death. Coroners do not investigate aspects of care that have not contributed to a person’s death,” he wrote.
“The limitations on this jurisdiction sometimes lead to the result that concerns raised by families are not able to be investigated because they are not sufficiently connected with the cause and circumstances of their loved one’s death.”
He concluded his death “appears to have been a tragic outcome of all the culminating factors, and there was no clear point in time when his death may have been prevented”.
“This was despite him having a loving, dedicated and resourceful family who sought all the resources and support that were available to them,” Coroner McGregor wrote.
The teen was remembered by his parents as “a brave and spirited person, who lived life with intensity and wild abandon”.
