The mother of a 23-year-old woman who died by suicide claims a "reprehensible" lack of action by ACT government services failed to keep her daughter safe from harm.
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Her comments follow a coronial inquest that found scant supervision and stretched resources meant a court order was nothing more than a "paper tiger".
Bronte Elouise Haskins, nicknamed "Poppy", died by suicide in February 2020.
Bronte battled mental health and addiction issues before her death, which occurred outside a Higgins home occupied by her former partner convicted drug trafficker Brett French.
In a statement on Wednesday, Bronte's mother, Janine Haskins, said: "I strongly and firmly believe that if it weren't for the reprehensible actions, or, rather, lack of actions provided to keep Bronte safe from harm, she would still be with us today."
"The services who failed our gorgeous girl need to be accountable for what I can only determine to be negligence.
"Losing such a loved and cherished child and sister is the worst thing imaginable."
In findings published on Wednesday, coroner James Stewart found no-one could be blamed for Bronte's death.
However, he found a series of "lost opportunities" had contributed to the "premature and sorrowful end to the story of Bronte's life".
Mr Stewart said Bronte had "brought light to many people and, apparently, to many animals as well".
The coroner acknowledged evidence presented during the inquest hearing had "painted a picture of a deeply troubled young woman".
Mr Stewart said Bronte had been "exposed to multiple negative and harmful experiences and suicide risk factors". He said she was "no stranger to suicide and suicide attempts".
He found Bronte's family had been stuck "in a terrible situation" and believed, in the days before her death, their daughter had relapsed into heroin use and was mentally unwell.
However, the family "did not want to harm a newly emerging relationship of trust with Bronte by incessantly involving authorities with Bronte or attempting a hospital admission themselves", Mr Stewart said.
Bronte was on bail at the time of her death. She had been arrested for driving while suspended, drug-driving and failing to stop at a stop sign.
Bronte's bail officer, Sarah Karchinsky, was one of only two bail officers in the ACT at the time and managed between 120 and 130 cases by herself.
The coroner said he was "genuinely shocked by the under-resourcing that allowed for the scant supervision of Bronte".
"This inquest has changed my whole view of the utility of supervision by ACT [Corrective Services] as a bail condition and left me in shocked awe at the workload put upon the bail supervisors.
"The 'hands-off' approach to supervising Bronte made her bail agreement little more than a paper tiger for the most part of it."
Among a series of recommendations, Mr Stewart said his findings about the inadequate level of supervision should be brought to the attention of Attorney-General Shane Rattenbury and Corrections Minister Mick Gentleman.
He also recommended that bail officers be trained in basic suicidality assessments, and consideration be given to funding 48-hour turnaround bail assessment reports.
Bronte was also under the supervision of the Court Alcohol and Drug Assessment Service at the time of her death.
The coroner said he was "underwhelmed" by what this meant for Bronte in real terms.
This also had resulted in more "lost opportunities" for intervention in Bronte's drug use and mental health issues.
Yet another opportunity was lost, Mr Stewart found, when Bronte's mother called Access Mental Health to try and arrange help for her daughter.
However, triage officer Karina Boyd failed to correctly categorise Bronte, meaning that a vital follow-up did not occur.
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"That follow-up should have taken place regardless of police attendance - hence my view that an opportunity to assist Bronte was lost," Mr Stewart said.
Speaking with The Canberra Times on Wednesday, Bronte's mother said she found the coroner's recommendations "beige" and was "underwhelmed".
"[The recommendations] will just end up in a cabinet somewhere," she said.
"The system is broken and continues to let our loved ones and other people down.
"I intend to meet with the Attorney-General. I'll go in hard and hopefully we won't have others fall through the cracks.
"Why do we have to wait for a death [before we] fix things?"
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