A Brighton mother said that she was pleased lessons would be learnt after her troubled 17-year-old son killed himself.
Barbara Bonnot was speaking after an inquest at which West Sussex coroner Penelope Schofield found that Steffan Bonnot committed suicide.
The coroner said that Brighton and Hove City Council, which was responsible for Steffan’s care, had accepted the findings of a serious case review by an independent expert Fergus Smith.
But she said that she had some concerns about how and when information was given to foster carers in light of evidence from Mr Smith about the challenges facing social workers.
Mr Smith said that they didn’t always give the proper paperwork to foster parents, perhaps because they were having trouble managing their workload or because timescales were tight for emergency placements.
The coroner, in an attempt to prevent future deaths, will ask Ofsted and national safeguarding chiefs to ensure the proper procedures are followed.
Mrs Schofield said that Steffan had “a difficult and complicated childhood and had spent most of his life in care”.
She praised the exceptional care at the Amicus Community and the stability that it gave Steffan for the final years of his life while acknowledging his anxiety about leaving as he approached the age of 18.
The coroner also praised Steffan’s social worker Siren Harradine-Miles. She had played a key part in providing an impressive continuity of care, the inquest heard.
Mrs Bonnot had been keen for her son to stay with the Amicus Community, in Rustington, but the inquest, in Crawley, was told that this would have been almost impossible.
Mrs Schofield said: “As Steffan was moving towards his 18th birthday it was going to be necessary to move him from the Amicus Community.
“He was due to move into foster care in the second week of January. A transition plan had been put in place which included a number of pre-visits to his new foster carer.”
The coroner noted the dispute about the pace of change but added: “Foster care was not something new to Steffan.
“He’d had a large number of placements which had broken down for one reason or another.”
He was by turns anxious, excited and ambivalent and his mother and staff at Amicus felt that he was reluctant about the placement.
The coroner said that when Steffan had visited his mother over Christmas 2015 he had said that it was going to be his last Christmas.
When opening presents, he had said that he wouldn’t need them where he was going.
Unbeknown to her, he had also been researching sites on the internet about killing himself.
He took his life after walking off after an outing to the cinema from his Amicus home on New Year’s Day 2016.
He made his way to a foot crossing over the railway line at Warningcamp, near Arundel, and sent text messages to his family, social worker and friends stating or hinting at what he was about to do.
The coroner said that the train driver had seen Steffan kneeling on the crossing but couldn’t stop in time.
Mrs Schofield said: “The injuries that he received led to an instantaneous death. The cause of death was a blunt head injury.
“This placement was troubling Steffan. However, a great deal of effort was put into place to support Steffan.”
Although he had a history of self harm, no one realised he was suicidal, she said, and he was very happy at Amicus.
She added: “This is truly a tragic case of a life taken at such a young age.”
She offered her condolences “for the sad loss of Steffan” to Mrs Bonnot and praised her dignity, saying: “The death of Steffan has touched many many people.”
Barbara Bonnot said: “We’ve had justice today. I’ve got a good result for Steffan. I feel lessons will be learned and I’m pleased that some of these issues will be addressed nationally.
“It’s just sad that someone had to die first. I hope another family won’t suffer.
“Social services should be better trained in mental health so they’re aware of self-harm and things to look out for instead of judging individuals as attention-seeking or badly behaved.
“I just wanted them to say sorry. I’d like them to have said they should have listened to me more.
“I think they should listen to the actual carers who are looking after a child – and the parents.”
Steffan’s family remembered him as “mischievous” and “a handful”, with Mrs Bonnot saying that she would remember “his sense of humour, his cheeky little giggle and making me jump!”
She also smiled as she recalled him putting things on a high shelf out of her reach.
She said: “I can still hear his chuckle. I’ve got some really good memories and it’s the good memories that help you survive.”