Teen takes his own life after being moved around 18 different foster homes

Zhane Chilcott was in care since he was 12 months old

Among the failures in Zhane's case, were missed chances for early intervention, before he went into care, along with missed chances to deal with the trauma of multiple placements, and, in the lead-up to his death, missed opportunities to address psychiatric issues, the coroner found.

In findings released Thursday, Whittle said an analysis of those missed opportunities "does not lead with certainty to the conclusion that Zhane's death by suicide was preventable".

He did, however, find that there were a number of missed chances "to moderate" Zhane's risk of taking his own life: "Had those failings not occurred, it can only be said that the risk of Zhane taking his own life must have been reduced."

The inquest was told Zhane had been in some type of state care, or foster home, since he was age one.

This instability led to "minimal opportunity to develop meaningful and secure relationships with the adults who cared for him", Sally Giles, who was an assisting counsel at the hearing, said, according to the Mail.

She added that Zhane also suffered from a myriad of behavioural issues in care and at school, sparked by significant traumas and a lack of help at critical moments in his life.

The inquest heard, that at one point, Zhane was placed with an experienced foster carer and flourished, even being nominated for a leadership award. That carer could not continue to look after him though, without an increase in funds, which were refused.

The Mail reported, as a consequence of that, Zhane was placed in a facility that cost more for three months, than what the carer requested for a year.

Whittle recommended a risk register be established for kids in state care to record all threats or incidents of self-harm, and a review of payments to foster carers.

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