South Australian teenager Zhane Chilcott took his own life after being wheeled through foster care

A South Australian teenager who was moved between 18 foster homes and residential homes before taking his own life has been failed on multiple occasions by those responsible for his care, an inquest has found.

But state coroner David Whittle has not ruled the 13-year-old’s death was avoidable.

He said the circumstances surrounding Zhane Chilcott’s death in 2016 are complex and multifactorial, and the question of whether the boy’s death could have been avoided is therefore complicated.

Mr Whittle said failures in Zhane’s case included missed opportunities for early intervention before he entered care, missed opportunities to deal with the trauma associated with multiple placements and in the period just before his death several missed opportunities to address his psychiatric problems.

“An analysis of these missed opportunities does not lead with certainty to the conclusion that Zhane’s death by suicide was preventable,” the coroner said in his findings Thursday.

State coroner David Whittlee said among the failures in Zhane Chilcott’s case were missed opportunities for early intervention before he received treatment

“However, I feel that in Zhane’s case there was a number of missed opportunities to reduce the likelihood of death by suicide,” said Mr Whittle (pictured).

Opening the inquest, the attorney assisting Sally Giles said Zhane (pictured) had been in some type of government welfare or nursing home since he was 12 months old

“However, I find that in Zhane’s case there were a number of missed opportunities to reduce the likelihood of suicide.

“The cumulative effect of all these mistakes was to increase his risk of suicide.

“If these mistakes hadn’t occurred, one can only say that the risk of Zhane taking his own life would have been less.”

Opening the inquest, the attorney assisting Sally Giles said the teenager had been in some form of government welfare or nursing home since he was 12 months old.

She said his short life was marked by significant instability in placement, resulting in minimal opportunities to form meaningful and safe relationships with the adults who cared for him.

Ms Giles said Zhane also suffered from a variety of behavioral issues in care and at school, triggered by significant trauma and a lack of help at critical moments in his life.

Eventually, he was placed with an experienced caregiver in north-central South Africa, where he reportedly thrived, began attending school regularly, and was nominated for a leadership role.

But when the caregiver said he could not continue caring for the boy without an increase in funds, authorities had refused to provide additional money.

Instead, Zhane was placed in a dormitory for a period of three months at a higher cost than the caregiver had charged for a full year.

At one point, Zhane (pictured) was placed with an experienced caregiver in north-central South Africa, where he was said to have thrived, attended school regularly and had been nominated for a leadership role

Mr Whittle recommended that foster children give meaningful consideration to their contact with biological family members at least once every 12 months (pictured Zhane Chilcott’s sister Tanisha, stepsister Sarah Thompson, father, Keith Chilcott-Singpoo and brothers Graham and Leigh Stieer at a previous investigative hearing

Zhane (pictured) had also suffered from a variety of behavioral problems in care and at school, the investigative agency heard

In his findings, Mr Whittle recommended the establishment of a risk register for children in government care that would record any threats or incidents of self-harm.

He also called for a review of payments to family-based foster parents to increase the number of people willing to take children, and recommended that contact of children in care with biological family members be meaningfully accounted for at least every 12 months.

Regarding Indigenous children, Mr Whittle recommended that a recognized Aboriginal and Torres Strait Islander organization culturally linked to each child be appointed and consulted prior to any foster home or care placement.

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