Zhane Chilcott inquest finds systematic failures in state care increased his risk of suicide

Zhane Chilcott was just 13 when he took his own life in state care, after 18 different placements across his too-short life. Now a court has ruled on what could have saved him.

Multiple failures in the care of a young boy in state care increased his risk of suicide, but his death may not have been preventable, an inquest has found.

Zhane Chilcott was 13 when he took his own life at a residential care facility on July 12, 2016.

On Thursday, State Coroner David Whittle published his findings and found the circumstances of Zhane’s death were “complex and multifactorial”.

He concluded the risk of Zhane’s death would have been reduced had he not been subject to “missed opportunities in his care”.

In his short life Zhane had already been subject to 18 placements with foster families or institutions.

One of his foster families later faced criminal charges for allegedly assaulting Zhane while in their care. Those charges were dropped shortly after Zhane’s death.

Mr Whittle recommended any child scheduled to give evidence in a trial as an alleged victim should have an initial psychological analysis.

Zhane Chilcott, in a photo taken about a year before he died in 2016.

Zhane Chilcott’s sister Tanisha, stepsister Sarah Thompson, father, Keith Chilcott-Singpoo and brothers Graham and Leigh Stieer at an earlier inquest hearing. Picture: NCA NewsWire / Emma Brasier.

Zhane was only three months old when the first report was made to then Families SA about his welfare with his biological family.

Police attended the property and found Zhane alone with his siblings. Both the children and the home appeared “neglected” according to police.

He was left in the care of his parents but removed six months later after five more neglect reports.

Zhane spent six years with a family in Adelaide but that care ended after he reported physical and sexual assault at the hands of one of the family members.

He found stability with foster carer Stephen Rimes in a house near Gladstone, however funding issues led to Zhane returning to a residential facility.

In the months before his death Zhane threatened self-harm if he was returned to the residential facility where he was living.

Zhane Chilcott’s former foster carer Stephen Rimes outside the Coroner’s Court. Picture NCA NewsWire / Emma Brasier.

Despite having a background of severe trauma, an internal report found there was “no urgency” in getting Zhane psychological treatment after he was sent back to the city.

Mr Whittle recommended each child in the state’s care should have the possibility of contact with their biological parents considered every 12 months.

He also recommended children from an indigenous background be linked to a registered indigenous organisation when they first enter care and remain in contact with social workers.

Mr Whittle declined to recommend all children in state care have a psychological assessment every 12 months.

“The resources (both financial and human) available to provide psychological services to children in care are finite and most appropriately concentrated on those children and young people who have experienced trauma and who present with disabilities or other complexities,” he said.

“On balance, having regard particularly to the number of children under guardianship, I conclude that the proposed recommendation would not be achievable, and I make no recommendation.”