First Nations readers are advised that this story contains images and names of people who have passed away.
The New South Wales Coroner has begun the hearing into the death of George Campbell, a Yuin-Dunghutti-Tharawal 17-year-old who was in the care of Department of Communities and Justice when he was found dead in Wallaga Lake on 10 March 2018.
The inquest comes as a rare examination of the death of a person under state care but not incarcerated, and, advocates say, provides an opportunity to uncover possible systemic problems in the child protection system.
On Tuesday, the first day of the hearing, evidence emerged suggesting that in the months leading up to his death, the Department failed to adequately communicate important information to Mr Campbell's psychologist and psychiatrist, such as the basic details of his carer and a background brief on the teenager.
It also emerged there was a lack of continuity of care and follow-up when Mr Campbell's caseworkers changed, with a former Department caseworker acknowledging there was no formal handover between his different caseworkers.
On Wednesday the Department faced further questions on whether adequate cultural and social support was provided to the teenager in the lead up to his death, including opportunities to connect with his birth family.
Mr Campbell went missing on 9 March 2018, and the following day his body was found at Wallaga Lake. It is suspected he died as a result of the misuse of volatile substances.
His family say the Department should have given more support to the teenager while he was in their care.
George's mother Karen Campbell said the family "wants to know what happened to George and whether there were any failures in the care he received in the lead up to his death".
"George was a loved member of our family. He always made everyone laugh and we miss him each and every day," she said.
National Justice Project solicitor Karina Hawtrey said the firm "will be standing alongside our clients are they seek to find out what happened to their beloved son".
"The family have asked for answers about what DCJ was doing to support George leading up to his death, and they want some accountability for the heartache that they are suffering," she said.
A 2019 independent report, Family is Culture, found that the out-of-home care system administered by the NSW Department of Communities and Justice lacks cultural competency and trauma-informed approaches and made 125 recommendations to address the issues in the child protection system.
In a May 2022 report to the Office of Children's Guardian, the Department acknowledged key reforms to which it had committed had not yet been implemented, saying it lacks the financial and human resources required to make the changes.
A Department of Communities and Justice spokesperson told National Indigenous Times that the NSW government is "committed to reducing the over-representation of Aboriginal children and families in the child protection system".
"For the first time in five years there has been a reduction in the number of Aboriginal children in out of home care, down by 16 per cent. The priority is to work with Aboriginal communities to improve services and better support Aboriginal children and families," she said.
"Nearly all of the over 3,000 recommendations from the 2019 Family is Culture review that related to individual case files have been completed. Of the 126 systemic recommendations made, 25 were related to changes to laws and court processes designed to increase accountability and transparency of the system.
"The government consulted broadly with stakeholders on these recommendations - including with Aboriginal people and Aboriginal community organisations, legal and court stakeholders, child protection casework, policy and operational staff, and other government agencies, including Community Legal Centres (NSW)."
The spokesperson noted that in August 2022, the Department released a consultation report that outlined the proposed legislative changes to give effect to 15 of the Family is Culture review recommendations and, after further stakeholder engagement, in late 2022 the NSW Parliament passed the Children and Young Persons (Care and Protection) Amendment (Family is Culture) Act.
"These amendments are designed to improve service delivery and decision making for children and families in contact with the child protection system, including the requirement that active efforts be taken to prevent children entering out of home care and restoring them to their parents or kin," she said.