Didbala Anzac, 17

Didbala was a 17-year-old Aboriginal girl with very complex trauma, disability and mental health needs, who died by suicide while living in intensive therapeutic residential care. Although she had been identified as potentially eligible for NDIS support in early 2021, her NDIS application was not submitted until September 2022.

The coroner called the delay a “stark example of Case Management neglect”, and described it as alarming that Territory Families had no benchmark timeframes for progressing NDIS applications. The broader conclusion was that multiple systems failed to deliver the care Didbala required — the NDIS delay was one important strand rather than the sole cause of her death.