Steffan Bonnot · Prevention of Future Deaths report

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

Steffan was a young man who has had spent a considerable amount of time in foster care and children’s homes. He was due to move out of the Amicus Community Children’s home and into another foster placement on 16th January 2016. It was clear from the evidence that he was concerned about leaving the Amicus community and that he was anxious about whether or not the Foster Carers were fully appraised of his background. He had had a large number of Foster placements in the past many of which had broken down. The concerns he had about how much the Foster Carers knew caused him some anxiety.
On Friday 1st January 2016 Steffan was amongst a small group of children who attended the local cinema. This was a pre-arranged outing. On the return from the cinema Steffan’s group, which consisted of two staff and another child, stopped off at MacDonalds. Shortly after arriving at MacDonalds Steffan and the other young man went to the Toilet. A member of staff followed them shortly afterwards and asked them to come out. Steffan did so but then left MacDonalds without saying anything. The staff tried to follow him and locate him. They were unable to do so and sadly Steffan body was later found at the Warnningcamp footcrossing having been struck by a train. Steffan had deliberately knelt down in front of an oncoming train.

1. The author of the serious case review reported that the prospective foster carers who were to offer a placement to Steffan had advised that they had not been made fully aware of all the background to Steffan’s case. This was, however, at odds with what Steffan’s Social worker told us. However there was no formal documentation detailing exactly what had been disclosed. It 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.
2. The above concern would apply equally to any individuals entrusted with the care of a child. All 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.

I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other patients.