"I identify as a proud Wemba Wemba women [sic] and would like the associated support that a young Aboriginal female should be provided with further care. This is a human right," a young girl, taken from her family and put in the child protection system in Victoria, wrote in December 2020.

It is a system that is struggling with systemic racism, Coroner Simon McGregor said on Wednesday.

The child, known by the pseudonym XY, had another request: "I would like support with connecting with my Aboriginal heritage, Elders and community, and I would like the Aboriginal community to support me".

This request, like many others she made to child protection to connect with her Indigenous culture, was ignored.

Seven months later, aged 17 and living in residential care in regional Victoria, XY took her own life.

"XY had a voice, and it was articulate," Mr McGregor said. "Sadly, it was not heard in time."

In the Coroner's Court on Wednesday, Mr McGregor said XY had been removed from her family and separated from her eight siblings at age 13; her requests to stay in contact with her culture repeatedly ignored in what he described as a breach of XY's human rights.

In this time, she experienced seven different out-of-home (OOHC) care placements.

She also did not have a relationship with her mother, in part because her mother did not believe allegations made by XY that her stepfather (XY's mother's partner at the time) had sexually abused her.

"It is hard for me to write this statement," her mother wrote after XY's passing, "because I don't have a lot of information about XY. I lost a chunk of her life."

"When she was in care, I lost touch with her. So, I can't tell a big story about XY because I missed those teenage years. That's something I have to live with forever because those are years I can't get back."

She remembered XY as a "beautiful, bright young spirit who was taken too soon," who loved to "sing, dance and dress up".

Her kinship carer, Jacquii Jackson spoke of XY's spirit, noting the 17-year-old "had many wonderful qualities and was a beautiful child and also, she had so many struggles on a daily basis, she always tried her hardest to push through".

When she took her life in July 2021, XY was under the care of Victoria's Department of Fairness, Families and Housing (DFFH) and living in an Anglicare-run residential unit in Bendigo.

In response to the December letter, the DFFH reminded XY of the importance of attending their care meetings Mr McGregor said, but made no systemic changes and failed to take her views on reconnecting with her heritage and culture seriously.

Furthermore, despite XY expressing a desire to connect and have a relationship with her siblings, McGregor found this not to be the case.

He recommended the DFFH "engage with its stakeholders to review their existing training programs so as to ensure that…the continuing systemic racism and paternalism inherent in child protection work today that must be identified, acknowledged and resisted".

In OOHC she reported sexual abuse, which was reported to police, and suffered from suicidal thoughts, eating disorders, self-harm and substance misuse. During her questioning by police, no Aboriginal liaison officer was present with XY, Mr McGregor found.

Mr McGregor found drug and alcohol services - whilst available to XY - "none…are yet tailored towards the special needs or vulnerabilities of Aboriginal people".

Furthermore, he said non-medically trained staff were charged with monitoring XY's declining mental health.

An independent Aboriginal expert panel said the care provided by the DFFH - and its contracted providers - meant XY "was not culturally connected and failed to recognise culture as a protective factor against suicide".

In a submission, the DFFH acknowledged the need to pay attention to shortcomings in when caring for children but argued it'd be "overly simplistic to characterise the actions of Child Protection as devoid of awareness of the importance of culture".

In his 17 recommendations, McGregor recommended the DFFH move towards transitioning all First Nations children in the state's child protection system to the care of a ACCO's, recommended by the Yoorrook Justice Commission last year.

Earlier this week, Guardian Australia revealed internal documents which showed the DFFH was preparing for a "likely transfer" of powers to Indigenous groups as a result of the Treaty negotiations between the First Peoples' Assembly and the state government - to begin later this year.

He also recommended the Department of Health, DFFH and Bendigo Health "coordinate culturally appropriate drug and alcohol support for young Aboriginal and Torres Strait Islander people", as well as organisations who look after First Nations children in OOHC (other than ACCOs) review their practices as to ensure they provide culturally connected care.

13YARN 13 92 76

Aboriginal Counselling Services 0410 539 905