A coroner has found a North Queensland teenager would not have have died if car keys in youth residential facilities were kept more secure.
Bailey Pini was 13 years old when he stole the overnight officer's car and drove two and half hours to his hometown in Bowen, where his mother had been buried nearly exactly one year earlier.
He crashed into a tree in the morning of June 9, 2020, rolling the car and trapping himself and his passenger upside down.
Both were rendered unconscious.
Flames erupted from the bonnet of the car as bystanders pulled Bailey's passenger from the wreck, but when they went to retrieve Bailey it was too late.
The inquest into his death heard the fire was "unsurvivable" and Bailey died at the scene.
Coroner Nerida Wilson gave her findings at Cairns Courthouse today.
The inquest examined the security and supervision at the care facility and whether the decision to place Bailey in the facility at Sarina was appropriate.
The inquest heard from barristers Anthony Collins, representing the non-for-profit facility, Karen Carmody from the Department of Children, Youth Justice and Multicultural Affairs, and counsel assisting John Aberdeen.
'Disowned' and 'evicted'
Bailey was placed in state care one month before his death.
Neither his surviving family nor foster carers could accommodate him.
"At the time of his death, Bailey was suffering deep trauma from the death of his primary caregiver, the rejection of his surviving parent, and displacement," Magistrate Wilson said.
She said after the death of Bailey's mother his father had "disowned him, evicted him" and, during the Easter holidays, placed him with a friend.
Despite the Sarina care facility being located 220 kilometres from Bailey's community, Magistrate Wilson said she believed Bailey's placement in the facility had been appropriate.
Magistrate Wilson said she took into account that there were no licensed care services in Bowen, as well as staffing and housing challenges.
She said conversations were held with his family prior to his placement, but no kinship options were identified.
"I did consider in hindsight, given the geographical distance from his home base in Bowen and the potential trigger of the first anniversary of his mother's death, that some provision should and could have been made … to transport him to Bowen to visit his sister, grandmother or family," Magistrate Wilson said.
Lock and key
The overnight officer whose car was stolen suffered an aneurysm in the year after Bailey's death and did not give evidence at the inquest.
The inquest heard the woman in her 60s had placed her keys in a tray in the office, which was locked and reinforced with Crimsafe screens.
Bailey and his passenger broke into the office by making a hole in the wall, but they were not the first at the residence to try and steal keys.
Magistrate Wilson said it was foreseeable that the youths would try again.
"The policies should be reviewed to require the installation at vulnerable residential facilities of a small safe, a key safe, fixed to the floor or wall," she said.
Magistrate Wilson said fitting alarms to the safes would be sensible.
"The [facility] is a registered charity and [has] an ever-increasing responsibility," she said.
"It is not a realistic option to convert offices in residential facilities to fortresses.
'The last bastion'
The inquest heard the boys living with Bailey had become "troublesome" and that staff had held meetings prior to his death about how to best deal with them.
It also heard that staff on overnight shifts worked alone most of the time.
Magistrate Wilson said she admired the overnight officer's conduct in trying to deal with the "out of control" teenagers the night before Bailey's death.
"The overwhelming sense is that a mature lady of 63 years, albeit with appropriate training and experience, was expected to contain the situation," she said.
Magistrate Wilson said it would ideal to have funding available for cases where an extra carer was needed in emergencies, but staffing levels did not contribute to Bailey's death.
She said if the lock boxes were introduced there would not be the need for additional staff.
But in her conclusion, Magistrate Wilson said the funding arrangements between the facility and the Department of Children, Youth Justice and Multicultural Affairs should be reviewed.
"It should not be the case where the system is stretched to the point where one 63-year-old woman becomes the last bastion between the residents and car keys, which in this case, provided the means of the collision," she said.
While this inquest only examined conditions at the Sarina home, the coroner said the findings would be relevant to similar facilities around the state.
