1. Child Deaths South Australia 2005–2021
1.1. Analysis and review of child deaths
The intent of the Committee is to improve the safety and wellbeing of children and young people in South Australia. It does this by collecting information about the circumstances and causes of all child deaths in South Australia, analysing and reviewing this information, making recommendations to relevant agencies, and monitoring the implementation of those recommendations. The Committee reviews specific cases of child death, and from time to time also reviews and analyses information about serious injuries.
1.2. Rates and patterns of death
Opportunities for prevention and intervention to improve the safety and wellbeing of children and young people can be identified through the systematic collection and analysis of information about child deaths. Section 37 of the Children and Young People (Oversight and Advocacy Bodies) Act 20161 identifies those deaths as eligible for review if: (a) the incident resulting in the child’s death or serious injury occurred in the state; or (b) the child was, at the time of the death or serious injury, ordinarily resident in the state.
As required by the Act, the Committee maintains a database of child deaths and serious injuries, to which it continually adds information that informs its analyses about rates and patterns of child death in South Australia. Figure 12 shows death rates for all children and young people who died in South Australia during the 16 years from 2005 to 2020, while Figure 2 shows death rates for children and young people who were usually resident in South Australia3.
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As shown in Figures 1 and 2, there has been a long-term downward trend in the rate of death of children and young people in South Australia. In 2019, the Committee reported 81 deaths – the lowest on its record since 2005 and a substantial drop from previous years. As discussed in Section 1.7.1 of this report, this was due in part to a reduction in neonatal deaths. In 2020, there were 73 deaths. The reasons for this further drop are not yet clear and may include factors associated with the COVID-19 pandemic. The Committee will undertake further analysis to explore this issue.
2 For each figure in Section One, there is corresponding data on Data.SA.
3 During this 16 year period, the average yearly population of children and young people aged 0 to 17 was 356,741. For more information on how this number was calculated, see Section 3.1.3
1.2.1. Death rates by region
Important issues for service planning and delivery are highlighted when death rates and numbers of deaths are mapped against the South Australian Government’s twelve administrative regions.
The highest rate of death for children and young people is associated with living in the Far North region of the state. In contrast, the greatest number of deaths is recorded in the Northern Adelaide region. Services should be planned and delivered to take into account regions where the rate of death is highest, and regions where the greatest number of deaths occur.
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1.2.2. Death rates of non-resident children and young people
Ninety-five (5.9%) of the 1712 children and young people who died in South Australia between 2005 and 2020 were usually resident in another state, territory, or country.
Figure 5: Number of deaths by state, territory or country of residence and cultural background, for children and young people not usually resident in South Australia, 2005–2020
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Of the 95 non-resident children and young people who died in South Australia between 2005 and 2020, 48 were from the Northern Territory, and 30 of these 48 were Aboriginal children and young people.
Many of the deaths occurring in South Australia reflect cross-border arrangements where seriously ill children and young people are brought to Adelaide for treatment of complex medical conditions associated with extreme prematurity, infant and childhood illness, and various external causes.
On average, five non-resident children die in South Australia each year. Only one non-resident child died in South Australia in 2020, possibly reflecting reduced interstate and international travel due to the COVID-19 pandemic.
1.2.3. Death rates and socioeconomic disadvantage
More children and young people die in areas of South Australia where there are greater levels of socioeconomic disadvantage4 . The relationship between child deaths and socioeconomic disadvantage is shown in Figure 6. Deaths of all children and young people between 2005 and 2020, resident and non-resident, were included in this analysis.
Figure 6: Death rate by Index of Relative Socio-Economic Disadvantage for all children and young people who died in South Australia, 2005–2020
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4 For information on how socioeconomic disadvantage is defined and used in this Annual Report, see Section 3.1.4
1.3. Deaths of children and young people and the child protection system
The Committee continues to review deaths of children and young people where a child, young person, or their family had had contact with the Department for Child Protection (DCP) in the three years prior to death. The intent is to monitor the implementation of recommendations associated with these reviews, and to analyse the number and causes of deaths.
In the 16 years from 2005 to 2020, 473 (28%) of the 1712 children and young people who died, or their families, had had contact with the child protection system. Of these 473 children and young people, 227 (48%) lived in the state’s most disadvantaged areas5.
5 As represented by postcodes within the lowest relative disadvantage SEIFA quintile within South Australia. For more information on how socioeconomic disadvantage is defined and used in this Annual Report see Section 3.1.4.
1.4. Deaths of infants and children whose parents had been in State care
The Committee reviewed the life circumstances of seven parents (four women aged 23–36 years, and three men aged 24–29 years), focusing on their life circumstances at the time of their infant’s death.
This was the Committee’s third review of parents who, at some point in their own childhood, have been placed in state care6 and subsequently had an infant who died. Each review has documented a different aspect of this experience: the issues that led to the parent’s placement in care, their experiences in care, and the impact that these experiences had on their life trajectories.
In the Committee’s view, measures are needed to acknowledge and address the challenges that arise in the lives of these parents, including:
- experiences of abuse, neglect and cumulative harm
- socioeconomic deprivation, reflected in unemployment, poverty and housing instability
- mental and physical health problems
- violent and aggressive ways of relating that may result in perpetrating, and/or being the victim of, severe and frequent domestic violence
- damaged relationships
- the death of a child and/or the loss of a child(ren) taken into state care.
Of note is that the circumstances of these parents’ lives reflect the results of several other recently published research studies7. The studies provide compelling evidence of poor outcomes for children and young people who have experienced state care, and their infants. For example, a retrospective cohort study of all persons born in South Australia between 1986 and 2003 found that by 33 years of age, the death rate for those who had at least one out-of-home-care placement was 30.9 per 1000, compared to 5.1 per 1000 for those with no child protection system contact8.
The Committee notes the policies and programs referred to in the South Australian Government’s 2020 Annual Report Safe and Well: supporting families, protecting children, which have been designed to improve the short and long-term outcomes for children and young people placed in state care and, in particular, for those young people who are facing the challenge of ‘transitioning out’ of state care.
The Committee submitted this review and its associated recommendations to the Minister for Education. The Committee invited a response to its recommendations from the Ministers for Child Protection, Health and Wellbeing, and Human Services. At the time of writing, a reply had been received from the Minister for Human Services (Table 1). The Committee acknowledges that the reforms being undertaken by the Department of Human Services have the potential to positively impact the life trajectories of parents such as those who were the subject of its reviews, but remains concerned about the availability of sufficient funding and resources to meet the demand for these services.
|Recommendations and responses|
Responses to recommendations were invited from the Ministers for Child Protection, Health and Wellbeing, and Human Services.
Services across the whole of government must be provided that reduce the likelihood parents will experience the loss of their children – through death, or the child’s entry into State care – by:
Response, Minister for Human Services
Child and Family Support Systems (CFSS) reform strategies aligning with this recommendation include:
Investment in independent research that tracks the long-term outcomes for children and young people who have experienced state care.
Response, Minister for Human Services
This department will be investing in university research that ‘deepens understanding’ about service needs and approaches for young people who have experienced trauma and that monitors the outcomes of its CFSS programs.
6 For the purposes of this review the Committee defines ‘in State care’ as any period of time when the child or young person was placed under the Guardianship of the Minister.
7 Segal L, Armfield J, Gnanamanickman D, Preen D, Brown D and Nguyen H (2021) Child maltreatment and mortality in young adults. Pediatrics, 147
Armfield J, Gnanamanickman D, Johnston D, Brown D, Nguyen H and Segal L. Intergenerational transmission of child maltreatment in South Australia: a retrospective cohort study. Lancet 2021
1.5. Deaths of Aboriginal children and young people
During the period 2005 to 2020, Aboriginal children and young people constituted 4.4% of the South Australian population of children and young people, but they accounted for 12% of child deaths. The rate of death for all Aboriginal children and young people who died in South Australia was 82 deaths per 100,000. For Aboriginal children and young people who were usually resident in South Australia, the death rate was 66 deaths per 100,000 over the same period (Figure 7).
This difference in rates reflects the number of children and young people with complex medical conditions who were retrieved from other states or territories for treatment in South Australian hospitals (see Section 1.2.2). The rate of death for non-Aboriginal children and young people was 28 deaths per 100,000. The rate of death for non-Aboriginal children and young people usually resident in South Australia was 27 deaths per 100,0009.
Figure 7: Death rate by cultural background for all children and young people, South Australia 2005–2020
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Figure 8: Death rate by cultural background and socioeconomic disadvantage, South Australia 2005–2020
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Figure 8 shows the death rate for Aboriginal and non-Aboriginal children and young people in each Index of Relative Socio-Economic Disadvantage quintile. The death rate for Aboriginal children and young people is significantly greater than for their non-Aboriginal peers, regardless of the level of socioeconomic disadvantage they experience. Note that the death rate for Aboriginal children and young people in the least disadvantaged areas has not been calculated because fewer than three deaths were recorded.
9 For information about the estimated population of Aboriginal children in South Australia see Section 3.1.3.
1.6. Deaths of children and young people with disability
Families caring for children with a disability face significant challenges in accessing services and support for their children. Information about the deaths of all children and young people in South Australia is reviewed by the Committee to determine whether a child or young person’s daily activities had been significantly limited by disability, and to explore connections between the disability and their subsequent death.
During the period 2005 to 2020, 379 of the 1712 (22%) children and young people who died were assigned disability status by the Committee10. On average, 24 children and young people who died have been assigned disability status each year.
In 2020, a review was submitted about the deaths of children and young people with disability who were placed in the care of others11. The review was based on the view that all children and young people, when placed in the care of others, are entitled to be kept safe and to have their needs understood and met. The Committee concluded that to prevent similar deaths, the quality and safety standards governing the practices of agencies who provide care for children and young people with disabilities must ensure that the most up-to-date information about that child or young person’s care needs is provided to them. Only then can a decision be made about the capacity of a facility to accommodate those needs, in terms of the level of staffing, the experience and training of staff, the physical amenities of the facility, and the available equipment.
The Committee’s recommendations were brought to the attention of key state and national agencies who hold responsibilities for the safety and wellbeing of children and young people with disabilities. A response was sent to the Committee on behalf of the NDIS Quality and Safeguards Commissioner which noted that the National Disability Insurance Scheme (Provider Registration and Practice Standards) Rules 2018 are subject to regular review and the Committee’s recommendations would be given detailed consideration in that context. A successful meeting was held with the State Director of the NDIS’ Quality and Safeguards Commission. The Committee will continue to provide its recommendations about improvements to safety and quality standards to the state body.
10 See Section 3.2.4 for the Committee’s definition of disability status.
11 Child Death and Serious Injury Review Committee Annual Report 2019-20, Section 1.5.1
1.7. Infant mortality
Of the 1712 children and young people who died in South Australia between 2005 and 2020, 967 (56%) were infants under one year of age.
Figure 9: Death rate per 10,000 live births by year of death and sex, for infants, South Australia 2005–2020
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As an official count of live births in 2020 is not yet available, the 2020 infant death rates shown in Figure 9 are calculated using predicted live birth counts12. These rates are therefore subject to change. For example, if COVID-19 has contributed to a decreased birth rate in South Australia, as it has in parts of Europe and the US13, then the infant death rate would be higher than reported here. The Committee will monitor this data and report any significant changes.
12 See Section 3.1.2 for details about how the imputed birth count was calculated.
13 Aassve A, Cavalli N, Mencarini L, Plach S, Sanders S. (2021) Early assessment of the relationship between the COVID-19 pandemic and births in high-income countries. PNAS, 118 (36) e2105709118; DOI: 10.1073/pnas.2105709118
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Figure 11 shows that the highest death rate occurred in the Far North region. However, from the perspective of service delivery, it is important to note that the highest number of deaths occurred in the Northern Adelaide region.
1.7.1. A reduction in neonatal deaths 2005–2019
In 2019, the Committee recorded the lowest number of infant deaths and the lowest infant death rate to date for the past 15 years. This was found to be largely due to a smaller number of neonatal deaths. Fourteen fewer neonates died compared with the previous 5-year average – a reduction of 37%.
The number of infants born in 2019 was not significantly lower than in previous years.
Figure 12 shows the results of an analysis of causes of death for neonates, comparing 2019 causes to the average over the previous five years by ICD-10 code block. The Committee’s blog post explores these issues in more detail14.
Significantly, in 2019, there were no deaths attributed to ‘Disorders related to length of gestation and fetal growth’ (block P05-P08)15. In previous years, these codes represented the second most common causes of death, accounting for an average of seven deaths per year. These deaths don’t appear to have been ‘pushed’ into other blocks, since there were no increases in the number of deaths in other blocks in 2019, with the exception of a small jump in block P00-P04.
The reasons for the reduction in deaths from the causes represented by these code blocks are likely to be multifactorial and complex.
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Referring back to Figure 9, the infant death rate – and the number of infant deaths – decreased further still in 2020. However, as COVID-19 has since introduced potential factors influencing birth rates and infant and neonatal mortality, this analysis has not been extended into 2020. The Committee will continue to monitor and explore these issues.
15 See Section 3.3.1 for further information about this analysis.
1.7.2. Sleep-related infant deaths and socio-economic disadvantage
On average, 13 infants die suddenly and unexpectedly each year in South Australia. Most of these deaths occur in the infants’ sleep environments, and in almost all cases at least one safe sleeping risk factor is identified. These risk factors are not necessarily causes of death in their own right, but rather behaviours or situations that increase the risk of infants dying after being placed to sleep – and they can be eliminated with education about, and adoption of, safe sleeping practices16.
Through prevention campaigns by organisations including Red Nose, Kidsafe SA, and SA Health, the number of infant deaths involving safe sleeping risks has declined over the past sixteen years. However, unsafe infant sleep practices, including unsafe bedding and bed-sharing, are still common and continue to contribute to the deaths of infants.
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The most common risk factor identified in sleep-related infant deaths – unsafe bedding – refers to any loose items present in the infant’s sleep environment. When placing an infant to sleep, it is important to ensure there are no suffocation hazards in the cot, including toys, pillows, and loose blankets. During the period 2005 to 2020, unsafe bedding was present in approximately three-quarters of all sleep-related infant deaths in South Australia (Figure 13).
Figure 14: Rate of sleep-related infant death by Index of Relative Socio-Economic Disadvantage, South Australia 2005–2020
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Almost half of all sleep-related infant deaths occurred in the state’s most socioeconomically disadvantaged areas. Infants in these areas were four times as likely to die suddenly and unexpectedly than infants who lived in the least disadvantaged areas (Figure 14). Many of these areas are located in the Northern Adelaide region.
The decline in infant deaths over the years indicates that prevention messaging and education are effective – but there is a need to continue targeted efforts to prevent sleep-related infant deaths. See the Committee’s blog post for a more detailed analysis of sleep-related infant deaths17.
Preventing sudden unexpected infant deaths – forum
In April 2021, the Committee and Kidsafe SA co-hosted a forum for agencies involved in managing service provision to vulnerable families and/or safe sleeping intervention and prevention. The focus of the forum was to:
- ensure that there is awareness of effort (ie, who is doing what)
- share information about what works and why
- explore opportunities for collaboration
- identify gaps in service provision and/or orientation
- agree to future steps.
At the conclusion of the forum, there was general agreement about the strength of universal prevention efforts, but also awareness about the need to focus on vulnerable families with targeted messaging and perhaps the identification of champions that different communities would recognise, relate to, and listen to. The group identified ‘touch points’ on the antenatal journey and could see a strong evidence-base emerging that supports the introduction of the Pēpi-Pod program to help prevent the sudden unexpected deaths of infants.
To progress co-ordinated prevention efforts, the Committee and Kidsafe SA have held discussions with Wellbeing SA about the development of a policy environment for the prevention of sudden unexpected deaths of infants (SUDI).
1.8. Deaths from illness or disease
During the period 2005–20, 1166 (68%) of the child deaths in South Australia were attributed to illness or disease. The majority (68%) of these deaths were of infants under one year of age and were associated with problems related to labour and delivery, chromosomal abnormalities, and congenital conditions without a precisely known cause.
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1.8.1. Policy direction and the wellbeing of children and young people
The Committee has continued to advocate for children experiencing lifelong chronic illness. Feedback was provided to SA Health’s consultation on the Women’s, Child and Youth Health Plan 2021–31 Summary Framework. The Plan prioritises service delivery to children, young people and families at risk, within its focus on all children and young people.
The Committee’s feedback emphasised the need for the Plan to have a focus on effective collaboration between SA Health, the Departments for Education and Child Protection, the Department of Human Services, and other relevant agencies to better support children experiencing lifelong chronic disease or disability. Such collaboration should take into account an understanding of research findings, consumer input, and policy development, and aim to include specific approaches to care coordination such as the Team Around the Child.
The Committee also recommended that the Plan address transition from paediatric to adult health care for children experiencing chronic health issues and suggested that families with diverse cultural or linguistic backgrounds continue to be prioritised within SA Health’s Plan for services from 2021–31.
The Committee met with the Child Protection Service of the Women’s and Children’s Health Network to discuss the neglect of critical medical care in families experiencing both high care needs and psychosocial complexity. The Committee noted that recognition of the neglect of critical medical care included factors of chronic non-attendance for health care, and the lack of identification of a family’s capacity to provide for a child’s complex care needs.
The Committee raised the benefits of generalist medical leadership in the management of complex chronic disease and early parenting capacity assessments. The Committee will progress its work on neglect of critical medical care with service systems in 2022.
1.9. Deaths from external causes
Deaths from external causes are those deaths that the Committee has classified as: transport-related, suicide, drowning, a deliberate act by another person, fire-related, accidents (falls, suffocation and asphyxiation, poisoning), neglect, and health-system related18.
1.9.1. The number and causes of deaths attributed to external causes
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18 For the Committee’s categories of death, see Section 3.2.3.
1.9.2. Deaths of children aged 0 to 12 years who were passengers in transport crashes
Between 2005 and 2020, 39 children aged 0 to 12 years died as passengers in transport crashes in South Australia. Twenty-five (64%) of these children were not appropriately restrained, including nine children who were unrestrained (Figure 18). Of these 25 children, half were aged 7 to 12 years and seated in an adult seat despite being less than 145 cm tall – the minimum height at which a person can safely use most adult car seats19.
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These data suggest that a principal issue is the lack of understanding of, and compliance with, safe child restraint practices. The law implies that most children can safely be transitioned to an adult seat when they reach seven years of age. However, most children are not large enough to do so safely until they are 10 to 12 years old.
Only one in approximately 14,000 children reach 145 cm by age seven. This nuance is not explained on Government road transport information websites20.
On the mylicence website, it is suggested that children should remain in a booster seat until they are 145 cm, but it is not stated as a requirement.
The Committee used these data to inform a submission to the draft of South Australia’s Road Safety Strategy to 203121 (the Strategy). The Committee expressed its concern that the Strategy, while acknowledging the use of child restraints as a target area, did not include any specific strategies, nor include any information on the issue of children prematurely transitioning to adult seats.
The Committee also queried the lack of recognition of ‘low-speed runovers’ in the Strategy. Deaths resulting from low-speed runovers involve infants and toddlers and usually occur at the child’s home with a parent as driver. Research by the Committee indicates that low-speed runovers, which disproportionately involve large SUVs, may be increasing. Four of these deaths occurred in 2019 alone in South Australia.
While these deaths do not occur on public roads, they are nevertheless road transport-related. In the Committee’s view, South Australia’s Road Safety Strategy should reflect this and protect South Australia’s youngest road users. Altering road user behaviour and promoting the use of safer vehicles are both key strategic focus areas in the Strategy and could contribute to the prevention of these deaths.
While these deaths do not occur on public roads, they are nevertheless transport related. Road transport – and road safety – does not end at the driveway, it begins there. If South Australia is to achieve zero transport-related deaths, we must prevent young children from being killed by vehicles at their own home. Our Road Safety Strategy should reflect this and protect South Australia’s youngest road users. These deaths can be prevented by altering road user behaviour and promoting the use of safer vehicles – both key strategic focus areas in the Strategy.
To inform future prevention efforts, the Committee will continue to collect and analyse data on deaths in similar circumstances.
1.9.3. Deaths attributed to drowning
Thirty-nine children and young people drowned in South Australia between 2005 and 2020, an average of 2.4 deaths per year. The average yearly number of drowning deaths has not decreased over time22.
Most drownings involve children aged 1 to 4 years and occur in private pools (Figure 19). Pool-related drownings are the most common type of drowning death – often involving non-compliant pool fencing, open or unlocked gates, and lapses in supervision. There were 16 such deaths in South Australia between 2005 and 2020.
About a quarter of the drowning deaths of children aged 1 to 4 years occur due to incidents involving bathtubs or other small bodies of water.
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Influence of cultural and linguistic background
Research suggests that people from culturally and linguistically diverse backgrounds are at greater risk of drowning23. Three of the four deaths occurring at ‘the groyne’ involved children and young people with diverse cultural and linguistic backgrounds.
The risk factors identified in these deaths were generally poor swimming ability and lack of understanding of the danger of rips, waves, and other ocean conditions. Although these risk factors may be associated with culturally or linguistically diverse backgrounds, they are not unique to these groups.
Summary and opportunity for prevention
The Committee will continue to contribute to the prevention of childhood drowning through engagement with key stakeholders in relation to the following issues:
- Water safety campaigns, especially focussing on domestic swimming pool safety and safety issues concerning inflatable swimming pools and provision of water safety programs – Kidsafe SA, Royal Life Saving SA, Surf Life Saving SA and the Office of Consumer and Business Affairs
- Legislative changes to promote swimming pool registration and regular pool maintenance inspections, with a focus on the role and responsibilities of local government – Attorney General’s Department and local government councils
- • Changes to safety signage to ensure its visibility and comprehension to those who may not speak English or be familiar with the symbols generally used – Minister for Planning and Infrastructure and local government councils
- Promoting the provision of timely and appropriate water safety programs for all children, including Aboriginal children living in remote areas of the State, children with disability and children from culturally and linguistically diverse backgrounds – Department for Education.
1.9.4. Deaths attributed to suicide
Between 2005 and 2020, 64 deaths have been attributed to suicide. These 64 deaths represent 4% of the total number of child deaths between 2005 and 2020. Forty (62%) of these children and young people were male, and 11 (17%) were Aboriginal children. Fifty-four (84%) of these deaths were of young people aged 15–17 years. Based on the Committee’s system of classifying deaths, this data makes suicide the third most common cause of death for young people aged 15–17 years, after transport-related deaths and deaths from natural causes (Figure 20).
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Review of suicide deaths and suicide prevention
The Committee has reviewed 57 suicide deaths using life chart methodology24. Based on similarities in their life circumstances, each of the 57 young people who suicided have been placed into one of four groups. Intervention and prevention strategies that are needed to address the issues in each of these groups have been identified.
Seventeen young people who suicided have been placed into this group. Fifteen of the 17 were males. These young people faced challenges in their family circumstances, with learning, and with relationships. At the time of their deaths, they were disengaged from family, from learning, and from their peers.
Intervention and prevention strategies need to begin early in life for young people to foster positive engagement with home, school, community and other forms of support.
Thirty-two of the 57 suicides reviewed were placed into this group. Eighteen of the 32 were male – a much more even split between sexes. The emergence of mental health challenges included depression and anxiety, deliberate self-harm and/or suicide attempts. Seeking help from youth-oriented mental health services was common but engagement was often not maintained.
Youth-oriented mental health services with an emphasis on assertive outreach are needed by young people who experience anxiety, depression and other mental health issues emerging in their teenage years.
The life charts of this small group of five young people showed positive engagement with family, their learning and peers. There was little evidence of mental health issues, but they had each experienced difficulties in social, romantic or sexual relationships in the year/months proximal to their suicide.
Readily available support and information services are needed for young people who are facing a ‘crisis’ in relationships upon which they have placed great emotional value.
The Committee does not have enough information about the three young people in Group 4 to determine common themes in their lives. More analysis may be possible in time, should further cases be added to this grouping.
Additional information about each of these groups and proposed prevention strategies can be found in previous annual reports and blog posts25.