Troubled Steffan Bonnot was 17 years old when he was killed at Warningcamp foot crossing, near Arundel, on New Year’s Day 2016.
Coroner Penelope Schofield concluded that Steffan, from Brighton, died by suicide when the inquest into his death resumed yesterday at Centenary House in Crawley. The first part of the inquest was heard in March this year, but was adjourned until now to allow a serious case review into Steffan’s death to take place.
Staff from Brighton and Hove children’s services faced questions over decisions that were made for Steffan in the months leading up to his death.
Steffan’s mother criticised the service for not apologising after the death of her son, whom she remembered as ‘mischievous’ and with a ‘childish sense of humour’.
Mrs Schofield was told at a previous hearing how Steffan had been in and out of a series of foster homes until he moved into the specialist Amicus Community in Littlehampton as a teenager.
But with Steffan approaching 18, steps were taken to put him in another foster home, as he could not stay at Amicus as an adult.
Steffan’s social worker Siren Harridean-Miles told the inquest the decision was made that Steffan would be settled with foster carers who would keep him on as an adult.
She told the coroner she spoke to Steffan about this plan many times: “He had anxiety as well as excitement.
“That is not unusual, it is a big thing moving into someone’s home.”
Steffan also discussed the move with his psychotherapist, Fiona Chandler, whose statement was read out at the inquest.
She said: “He was shocked and had not thought it was so soon, it was a blow.
“He was a damaged, vulnerable and disturbed boy with a history of emotional trauma.”
But she added: “As far as I was aware he did not have a history of significant self harm or suicidal thoughts.”
Fergus Smith, who wrote the serious case review into Steffan’s death, did not disagree with the decision to place him into foster care.
But he did raise concerns: “There were weaknesses in parts of the practices, in the transferring of information.
“There was some uncertainty about what was actually transferred to the foster carers.”
He said that it was possible the foster carers had been told important background information about Steffan over the phone, rather than being given it in writing to be carefully considered.
Mr Smith added: “I understand from Amicus that Steffan was concerned they did not know the whole story, he was left with an anxiety.”
But he said that there was no evidence there would have been a different outcome if changes had been made.
Coroner Penelope Schofield, concluding the inquest, said: “It is clear to me that this placement was troubling Steffan, but a lot of support was put in place.”
She said that nobody had forseen that Steffan had been considering suicide, but added: “I am troubled that it may have been on his mind for a while’.
Mrs Schofield added: “Certainly, the extent of Steffan’s stress at moving to his foster carers was not appreciated fully.”
She concluded that Steffan’s death had been suicide.
Turning to Brighton and Hove children’s services, she noted that recommendations from the serious case review that information be shared with foster carers fully and in writing had already been adopted.
However, she added: “There does appear to be a national problem, a problem of foster parents not being provided with that.”
She told the family she would be writing to Ofsted and the National Children’s Safeguarding Board to ensure that better practice was adopted nationwide.
Speaking after the inquest, Steffan’s mother Barbara paid tribute to her ‘mischievous’ son, whom she will remember for his ‘cheeky little giggle’ and trips to the beach.
She said: “I feel justice today, I have got a result for Steffan.
“I feel that lessons, hopefully, will be learned.”