South Australia's State Coroner has found the Department of Child Protection "missed opportunities" that "may well have prevented" the death of a 13-year-old boy who took his own life while in state care.
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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.
He left behind a note which said he did not want to be in care and wanted to be with his mother.
An inquest into Zhane's death had 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.
Coroner David Whittle found that "the cumulative effect" of the department's failings increased "his risk of suicide".
"The lack of oversight exposed Zhane to risks that he should not have been exposed to, including the potential for abuse," Mr Whittle said.
His findings stated the fact the 13-year-old had an unsigned case plan "reflects how out of touch Zhane's care team was with his needs in the months leading up to his death, and that his needs were being neglected and his case left to drift".
The report also stated that Zhane had found a successful placement with a man, Stephen Rimes, which "was the period of greatest stability in his entire life".
"He was happy and thrived in this placement," he said.
But Zhane could not remain under the care of Mr Rimes because the department chose not to support him financially, the coroner said.
"The breakdown of this placement was catastrophic for Zhane," the coroner said.
Mr Whittle found that the department's failure to keep Zhane connected with his biological family and culture was a "breach" of their obligations.
"The department failed by … neglecting to facilitate regular and meaningful contact between Zhane and his biological family, and failing to keep Zhane connected to his family, community, and culture," he said.
"The failure to facilitate meaningful family contact between Zhane and his biological family was not only distressing from Zhane's perspective, but was also a breach of the department's obligations."
'Meaningful' contact with biological family recommended
As part of his findings, Mr Whittle made numerous recommendations to try to prevent the recurrence of similar outcomes.
Mr Whittle recommended the establishment of a risk register, which records all acts or threats of self-harm by a child under the guardianship of the department's chief executive.
"There should be appropriate information sharing arrangements in place in relation to this risk register for all agencies that may deal with a child under the guardianship of the minister," he stated.
The coroner also recommended a review into the Complex Care Review Committee's policies and training to ensure cases like Zhane's were appropriately referred to the committee and not missed.
Mr Whittle said that each child under the guardianship of the chief executive must have contact with their biological family "in a meaningful way" at least once every 12 months.
He also recommended that all Aboriginal children under state care should be connected with a case worker or family member from the same Aboriginal or Torres Strait Islander community as the children.
The report also recommended a review into the payments made to family-based foster carers with a view to "increasing the availability of family-based placements for children".
