Coroner's Finding: Chilcott, Zhane Andrew Keith

Contributing factors

• failure to financially support stable foster placement leading to breakdown
• inappropriate residential care placement with multiple moves
• insufficient mental health assessment and therapeutic support
• delayed CAMHS referral with incomplete information about self-harm
• lack of family contact and cultural connection
• inadequate case management from geographically distant office
• failure to apply Aboriginal Child Placement Principle
• multiple placement breakdowns causing cumulative trauma
• formation of belief he would remain in care until age 18
• absence of key worker during critical period
• resumed contact with birth mother without adequate support
• pending court testimony as abuse victim without psychological preparation

Coroner's recommendations

1. Establish a risk register recording all acts or threats of self-harm by children under guardianship, with appropriate information sharing arrangements between DCP, CAMHS, CPS, DECD and SAPOL, reviewed regularly by qualified professionals
2. CAMHS review policies and training regarding referrals to ensure cases requiring Complex Care Review Committee assessment are not missed
3. Review adequacy of CAMHS services for children in state care and determine necessary funding to enable adequate services
4. Review payments made to family-based foster carers to increase availability of family-based placements, with particular attention to therapeutic carers' capacity to earn additional income
5. Require initial psychological consultation for any child due to give evidence as alleged victim once matter is listed for trial; ensure Witness Assistance Service is informed of psychologist and child's circumstances
6. Each child under guardianship must have contact with biological family considered in detail in meaningful way at least once every 12 months, including all siblings and parents, documented in Annual Review and C3MS
7. Appoint RATSIO (Recognised Aboriginal and Torres Strait Islander Organisation) culturally connected to each Aboriginal child at point of intake into child protection system
8. Implement policy for timely consultation with RATSIO before all placement decisions where practicable
9. Specify number of Aboriginal/Torres Strait Islander children with contact to case worker, community member or relative from same Aboriginal/Torres Strait Islander community in compliance with Section 156(1)(a)(iii)