UK Inquiry Tracker

Steffan Bonnot

PFD Report Historic (No Identified Response) Ref: 2017-0450

Date of Report 14 July 2017

Coroner Penelope Schofield

Coroner Area West Sussex

Response Deadline est. 8 September 2017

Other related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a risk to informed placement decisions.

View full coroner's concerns

_In_the circumstances my it is my statutory duty to 5981872.1 the the the January The had January from They having the report to you: The author of the serious case review reported that the prospective foster carers who were to offer a placement to Steffan had advised that had not been made fully aware of all the background to Steffan's case, This was, however, at odds what Steffan's Social worker told uS_ However there was no formal documentation detailing exactly what had been disclosed. was not therefore possible to be clear what information the prospective Foster Carer had been given: As we know the failing to provide Foster Carers with all the background information was one of Steffan's major concerns and added to his level of anxiety about his move The above concern would apply equally to any individuals entrusted with the care of a child. AlI relevant information should be made available and it should be documented as to what has been provided so that the carers can make an informed decision before any placement is agreed. The young person could then be confident as to what the prospective carer's knew. consider that the issues raised in this case should be addressed s0 that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other patients.

Sent To

Ofsted

Response Status

Linked responses 0 of 1

56-Day Deadline 8 Sep 2017

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 5'h July 2017 concluded inquest into the death of Steffan Bonnot born 6"h November 1988
17) who died on 1St January 2016. His Inquest was originally opened 12th (aged Conclusion that reached at the Inquest was that Steffan on January 2016. The was in the care of committed Suicide At the time of his death he Brighton and Hove Local Authority:

Circumstances of the Death

Soefien WAe a young man Who has had spent a considerable amount of time in foster care and children $ homes. He was due to move out of Amicus Community Children's home and into placement on 16th 2016. It was clear from the evidence that he was another foster the Amicus Community and that he was anxious about whether concerned about leaving appraised of his or not the Foster Carers were fully background. He had had ~large number of Foster placements in the past many of which had broken down: concerns he about how much the Foster Carers knew some anxiety: caused him On Friday 2016 Steffan was amongst a small group of children who attended the cinema; This was a pre-arranged outing: On the return the cinema Steffan's local of two staff and another child, stopped off at MacDonalds. Shortly after group, which consisted and the other young man went to the Toilet acDenabes oiSbortlolfceveariver shoracDofealdsrSteffiad asked them to come out Steffan did so but then left MacDonalds them shortly afterwards and to follow him and locate him. were unable without saying anything: The staff tried to do so and sadly Steffan body was later found at the Warningcamp footcrossing been struck by a train. Steffan had deliberately knelt down in front of an oncoming train

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action by addressing these issues.