An independent report looking into a decision to remove a boy from his foster care home and into residential care before he took his own life, has just been handed to the state coroner, despite being commissioned more than three years ago.

Key points:

  • Zhane was 14-years-old when he took his own life
  • He has been removed from his foster carer’s home and put into residential care
  • An inquest into his death heard the Department of Child Protection had commissioned an independent report, but it was not passed on to the coroner until Thursday

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 the boy’s 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.

A coronial inquest into his death previously was told the Department for Child Protection (DCP) made “critical failures” in its care of Zhane Chilcott, including failing to meet requests for funding from a previous foster carer.

It was told Zhane had been happily living with carer, Stephen Rimes, from 2014 to 2015, before being relocated to residential care, which cost the department four times as much money.

The inquest on Thursday heard from DCP chief executive Cathy Taylor who took over the role in October 2016, three months after Zhane’s death.

Zhane Chilcott died in 2016.(Supplied: Coroner’s Court of South Australia)

Ms Taylor said that, in 2017, she had commissioned an independent review into “how, why and who” made this decision, following discontent within her department.

“I was approached by several senior people from DCP who were concerned about the decisions that had been made by senior executives previously,” she said.

“They had concerns that the decision made to terminate Zhane’s placement with Mr Rimes had been wrong, and we needed to account for our decision-making.”

The report prepared by consultant Anne Nicolaou was handed to the Department in May, 2018, but was not presented to the state coroner until this week.

Ms Nicolaou’s report was damning of the department’s decisions to remove Zhane from Mr Rimes’s care.

“This review finds that the process that reached the decision not to support the placement, and the rationale for the decision itself, were both flawed, and not defensible,” she wrote.

“It is a tragedy for Zhane and his family that this did not occur.”

Zhane Chilcott on his second birthday, in a photo from a memorial booklet produced for his funeral.(Supplied: Coroner’s Court of South Australia)

Ms Taylor accepted “there were major faults in the department’s decision-making process and that there was a compelling case to keep Zhane in Mr Rimes’s care”.

“Zhane’s death was a tragedy and what he experienced from abuse in care, to decisions about his placements, all contributed to the outcome,” Ms Taylor said.

She also accepted that, as Zhane’s legal guardian, the department failed to safeguard his interests.

Chief executive denied lack of transparency

The inquest was told that Ms Nicolaou’s report was the first evidence the department had received detailing who exactly had made the decision to place Zhane into residential care.

“The decision was made by Ms Keogh, and endorsed by Mr Scheepers,” the report said.

Caroline Keogh was DCP’s assistant director, while Etienne Scheepers was its deputy chief executive.

Department of Child Protection chief executive Cathy Taylor says it didn’t occur to her to provide an independent report on her department to the coroner.(ABC News)

However, under questioning, Ms Taylor said “it didn’t occur” to her to provide the coroner with the report before now, and that she had not commissioned it in order to address the gaps of a previous inter-agency report.

“I commissioned the report from the perspective, I wondered, was I going to need to take HR action?” Ms Taylor said.

When asked whether she had formed a view as to how the department came to its decision-making process she said, “The only view I formed was, ‘Wow, we have some work to do’.

“And the second was how important it is that decisions are made, not from a financial lens, but from a clinical lens.

“Those were my two critical takeaways.”

She said the department had undergone major reforms to develop a “child-centred approach” to care, in line with recommendations made in the damning Nyland Royal Commission into the Child Protection System.

Counsel assisting the coroner Sally Gilles questioned Ms Taylor at length as to whether she had been deliberately obscuring Ms Nicolaou’s independent report from the coroner, which Ms Taylor denied.

“The Anne Nicolaou report should have been handed to the coroner in 2018, do you accept that?” Ms Gilles said.

“I certainly agree it would have been of great assistance to the coroner’s court to get that at an early stage,” she eventually admitted.

‘No secret’ SA performing poorly, report finds

The Nicolaou report was also scathing of the South Australian Department of Child Protection’s investment in family-based foster care.

“It’s no secret that South Australia is doing particularly poorly in terms of its current expenditure on out-of-home care [two-thirds of the DCP budget] and its much higher reliance on residential and emergency care,” the report said.

“There is a considerable body of literature on the preference for family-based care for children over residential care.”

Ms Taylor said DCP was attempting to address this issue and had employed 78 foster carers in the past financial year.

“We want to know we’re continuing to reach and grow the number and availability of family-based carers in South Australia.”

Ms Taylor told the inquest that, since she took over as DCP’s chief executive, the number of children in residential care had reduced by 3 per cent.

Still, the inquest was told that the number of children in residential care in South Australia was 14 per cent, almost double the national average of 8 per cent.

The inquest continues.

Posted , updated