A coronial inquest into the death of Brontë 'Poppy' Haskins, who took her own life while on bail, has found no one was to blame for the death of the 23-year-old.
Ms Haskins's death was referred to the coroner to investigate whether police, paramedics and mental health workers failed to do enough to prevent it.
Coroner James Stewart found there was an absence of blame however made a total of five recommendations highlighting a lack of resources for key services Ms Haskins was accessing before her death in February 2020.
"This hearing has identified no one that can be blamed for Brontë taking her own life," his findings read.
"With the benefit of hindsight, I have no doubt that every person involved with Brontë in the days and weeks prior to her death would have availed themselves of any opportunity to do something more to try and stop her death."
The coroner found a number of insights into Ms Haskins's death that led to her suicidal ideation, including illicit drug use in her teens, and a friend lost to suicide.
The coroner said the insights into Ms Haskins's life were not included in the report to "cause shame" but to paint a picture of a "deeply troubled young woman."
"[Ms Haskins] was exposed to multiple negative and harmful experiences and suicide risk factors, and was no stranger to suicide and suicide attempts," he said.
However, the inquest also found Ms Haskins had begun forward planning and had her hair done on the day of her death, telling the hairdresser of her plans to possibly open a cafe.
Inquest reveals workload pressure of bail officer
Ms Haskins had been out on bail a week before her death after being charged with driving offences, and as part of her conditions, she was to reside at her mother's home and report to her bail officer.
The inquest found Ms Haskins's bail officer, Sarah Karchinsky, was one of only two in the ACT and managed between 120 and 130 cases by herself.
The coroner broke down the number of minutes Ms Karchinsky would be able to spend on each case.
"Based on a 37.5 hour working week, there are 2,250 possible effective working minutes," Mr Stewart said.
"Presuming Ms Karchinsky had 120 defendants to supervise then she had an average of 18.75 minutes per defendant each week to do so.
"Despite the pressure of this workload, Ms Karchinsky had a telephone conversation with Brontë on 13th February 2020 and scheduled an appointment for 25th February 2020."
Ms Haskins had previously breached bail conditions in 2019 under Ms Karchinsky's supervision after returning a positive urine sample for opiates and amphetamines.
That breach had not been reported to the courts, something Mr Stewart put down to ACT Corrective Services (ACTCS) being under-resourced.
"The family has sought a recommendation that all breaches are reported within seven days of notification," he said.
"That would be ideal, but I expect that it may be hampered by the overstretched resources already imposed upon the bail supervisors."
Ms Haskins had also disclosed to her bail officer a month before her death that she had experienced six overdoses over six weeks.
Despite this, she was offered no further support.
Ms Karchinsky acknowledged in the inquest that she had not been trained in identifying the signs of suicidal ideation.
The Haskins family recommended bail supervisors receive mental health training, but the coroner said that recommendation was out of the scope of the inquest.
Mr Stewart made two recommendations regarding the workload of bail supervisors, including that ACT Attorney-General Shane Rattenbury and ACT Minister for Corrections Mick Gentleman were made aware of the evidence of the inquest and of the "manner and level of supervision provided to Brontë and presumably, other defendants granted bail in the ACT".
He also recommended that bail officers be trained in administering basic suicidality assessments.
"This inquest has changed my whole view of the utility of supervision by ACTCS as a bail condition and left me in shocked awe at the workload put upon the bail supervisors," he said.
"The resources allocated to bail supervision in the ACT as of February 2020 were inadequate and did not allow for an acceptable level of bail supervision."
Mr Stewart also recommended that consideration be given to funding 48-hour turn-around bail assessment reports for those applying for bail or bail variations.
He also added that ACT Health should consider what, if any, input it could provide to bail assessment reports from a policy perspective.
'Services failed our gorgeous girl'
Mr Stewart said Ms Haskins's relationship with drugs and her bail conditions were known by the Court Alcohol and Drug Assessment Service (CADAS), however, she did not receive any monitoring other than an appointment per week after her release from prison.
"The delay in commencing CADAS assessment and monitoring meant that there were lost opportunities for the assessment of and intervention in Brontë's drug use, mental health issues and suicidality," he said,
Mr Stewart said Mr Rattenbury and the Minister for Justice Health and Mental Health Emma Davidson should be "made aware of the evidence and findings on the timing, manner and level of CADAS assessment and monitoring provided to Brontë".
In a statement, Brontë's mother, Janine Haskins, acknowledged the number of under-resourced agencies involved in her daughter's life before her death.
"As stated by Coroner Stewart, many of these services are significantly under-resourced which clearly makes workloads for staff untenable," she said.
"This needs to be changed as a priority – more funding for staff and resources."
However, she said it was disappointing that a number of the recommendations the family had suggested be made by Mr Stewart were "outside the scope" of her daughter's inquest.
She called on Mr Rattenbury to "consider these issues requiring such needed change".
"To put [it] in simple terms, I strongly and firmly believe that if it weren't for the reprehensible actions, or, rather, lack of actions provided to keep Brontë safe from harm, she would still be with us today," she said.
"The services who failed our gorgeous girl need to be accountable for what I can only determine to be negligence.
"Meanwhile, fly high, fly free our beautiful Poppy girl.
"We miss and love you to the moon and back."
