Victorian Coroner Simon McGregor made more than a dozen recommendations on Wednesday, including several for the state's Department of Families, Fairness and Housing, after an inquest into the death of the teen.
The Wemba Wemba girl was under departmental care, living at a residential unit in Bendigo operated by Anglicare Victoria, when she took her own life in July 2021.
The girl, known as XY because she cannot be named for legal reasons, was removed from her family at age 13 following reports to child protection services beginning when she was aged 22 months.
Once in care, she disclosed experiencing physical and sexual abuse while at home, which was reported to police.
She was put in seven different care placements over four years, ranging from two weeks to 12 months, and suffered disordered eating, self-harm, substance misuse and suicidal ideation.
Mr McGregor investigated whether her care was culturally competent, the impact of housing instability, case management, and risk assessment.
He found she was disconnected from her Aboriginal culture and community supports when in care, had a limited relationship with her mother and no contact with her siblings, despite wanting to do so.
DFFH breached the teen's human rights in not taking into account her wishes, he said.
Mr McGregor stressed the importance of listening to the voices and lived experiences of children in care.
"The department had a procedural obligation to properly consider XY's human rights, which involved hearing her voice and properly considering her views," the coroner said in his report.
"Without these obligations, her charter right would be empty."
The starkest example of her lack of voice was shown through a letter the girl wrote to the department when she was 16, he said.
"I am writing this letter out of frustration as I do not feel I am being validated, supported or cared for properly by your services," the girl wrote in December 2020.
"I identify as a proud Wemba Wemba woman and would like the associated support that a young Aboriginal female should be provided with further care. This is a human right."
She felt disconnected to her people and community, and asked for support from the department to reconnect her with her Aboriginal heritage and elders.
Mr McGregor said DFFH failed to take her views from this letter into account and in doing so had limited her rights.
He said systemic issues, including racism and inadequate consideration of cultural safety, meant the policies for Aboriginal children in protection did not align with the principle of self-determination.
Further, case management, drug, alcohol and mental health services, and the housing options provided to XY were not tailored to the special needs and vulnerabilities of Aboriginal people.
He issued 17 recommendations, including that DFFH review its practices and policies for Aboriginal and Torres Strait Islander children to provide more culturally connected care.
The coroner recommended the department work towards transitioning all First Nations children in their care to an Aboriginal Community-Controlled Organisation and said workers within organisations involved in child protection should be given cultural and anti-racism training.
DFFH has been contacted for a response to the recommendations.
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