The Department for Child Protection made “critical failures” in the care of a 13-year-old boy who took his own life, leaving behind a note saying he did not want to be in care and wanted to be with his mother, a coronial inquest has heard.

Key points:

  • A 13-year-old boy took his own life in July 2016 
  • He was in state care at the time 
  • An inquest has heard there were significant deficiencies in his care

Aboriginal and Torres Strait Islander readers are advised this story contains the image and name of a person who has died.

The boy’s family has given ABC News permission for his name and image to be used.

Zhane Andrew Keith Chilcott died in July 2016, while he was living in a residential care unit at Morphett Vale in Adelaide’s south.

An inquest into Zhane’s death has heard his time within the Department for Child Protection — then known as Families SA — was filled with instability and that he lived in about 18 different placements including foster care, emergency commercial care and residential care.

It heard there were significant deficiencies and critical failures in the level of care and support the Department for Child Protection provided to him.

“Zhane’s short life was marked by significant placement instability leading to minimal opportunities to develop meaningful, secure relationships,” counsel assisting the coroner Sally Giles told the inquest.

“(There were) a myriad of behavioural issues in care and at school resulting from significant life traumas and a lack of continuing and persistent therapeutic involvement even at critical moments in his life.

“This inquest will scrutinise Zhane’s experience under the Guardianship of the Minister and what were significant deficiencies in the level of care and supported provided to Zhane.

Zhane was removed from his mother’s care before the age of one into the care of Families SA.

Zhane Chilcott, 13, endured 18 different placements including residential care before he died in July 2016. (Supplied: Coroner’s Court of South Australia)

Just prior to his death, Zhane had been granted reunification access to contact his biological mother.

The inquest heard on the day he died he was denied an opportunity to make a call to his mother because it was almost his bedtime, he threw a shoe at a residential care worker and said it was their fault he was not with his Mum.

He eventually calmed down and went to his room.

He was later found dead in his room with a suspected suicide note saying he always imagined what his life would be like if he had lived with his mother and sisters.

“I don’t want to be in care, I want to be with you Mum,” the note read.

“Mum, it’s not your fault I did this; it’s my choice.

“You will always be in my heart. I love you. Goodbye.”

Allegations of sexual and physical abuse

The inquest heard Families SA failed to properly investigate one of Zhane’s earliest foster carers who went on to allegedly sexually and physically abuse him.

Just days before Zhane was placed with that carer a notification was made against the carer alleging abuse against the carer’s biological child.

“Concerningly, Zhane started exhibiting worrying behaviours that should have led to an investigation of a number of responses including a minimum of more frequent home visits.”

A photo of Zhane when he was younger from a memorial booklet which was produced for his funeral.(Supplied: Coroner’s Court of South Australia)

The inquest heard in the six years Zhane was in that foster care placement, Families SA only visited seven times, despite new policies requiring staff to visit once a month.

He was removed from that placement after it started to breakdown. 

On one occasion, the carer was unavailable to pick Zhane up from school and refused police checks of the adults in her home.

Zhane later spent just under two years in “highly-inappropriate” commercial care before being placed with another foster care family which the inquest heard was “untrained and unprepared for the placement” including making emotionally abusive threats of rejection.

Forced into residential care after foster carer lost funding

The inquest heard Zhane was then placed with an experienced foster carer where he made significant progress, including attending school full-time in mainstream classes and being nominated as school leader.

It was in this placement where Zhane made a number of disclosures about physical, sexual and emotional abuse with his former foster carer.

That placement came to an end when the inquest heard the carer was forced to resign because his payments were significantly reduced by foster care agency Life Without Barriers and he had to sell his home.

The inquest heard Zhane wanted to live with his mother and sisters.(Supplied: Coroner’s Court of South Australia)

The inquest heard Zhane’s school principal and Department for Child Protection senior psychologist advocated for Zhane to stay in this placement and for the carer’s financial needs to be met.

But that did not occur and Zhane was later placed in residential care in Adelaide.

“At a cost of approximately $10,000 per week, a greater cost over the course of three months than his carer was seeking over the course of a year,” Ms Giles said.

The inquest heard his case manager remained in the state’s Mid North and had very little face-to-face contact with Zhane.

It heard his behavioural problems escalated, he started absconding and was suspended from school.

He started self-harming and making comments at school that he would kill himself if he was forced to return to his residential care home.

He died by suicide after seven months in residential care.

“There was no mental health service supporting Zhane and his key worker had gone on leave,” Ms Giles told the inquest. 

The inquest — which is expected to run for two weeks — will examine the critical failures made by Families SA and the progress on the implementation of recommendations made following the Child Protection Systems Royal Commission. 

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