There were "missed opportunities" by NSW government departments in the lead-up to the suicide of a 15-year-old First Nations boy in the Hunter Region in 2020, an inquest has found.
Deputy State Coroner Erin Kennedy handed down her findings on Friday, after a four-day inquest in Sydney in June.
Magistrate Kennedy said three government agencies each believed another was assisting with the case of the boy, who can only be identified as SG.
"There were a number of missed opportunities to ensure that [SG] received assistance," she said.
"If it had been made apparent to each that the file was closed, this might have prompted different action."
The inquest found that SG died by suicide in a Hunter Valley backyard on May 13, 2023.
The NSW Department of Family and Community Services received more than 40 reports regarding SG's circumstances from the time he was an infant, the inquest heard.
Magistrate Kennedy said one of SG's friends took him to speak with a school counsellor employed by the NSW Department of Education in December, 2019, at which time SG disclosed that he had attempted suicide a week earlier, citing depression brought on by abuse he was allegedly being subjected to at home.
The counsellor called SG's father and referred the teenager to Hunter New England Health's Child and Adolescent Mental Health Service.
SG did not attend two appointments that were arranged with the service.
A Risk of Serious Harm report was sent to Maitland Community Services Centre - run by the Department of Communities and Justice - four days after SG met with the counsellor.
It had a required response time of less than 72 hours, but was reviewed four days later.
A Department of Communities and Justice caseworker contacted the school counsellor, who said "several protective measures have been put in place".
The counsellor also told the caseworker the Child and Adolescent Mental Health Service was acting on her referral but was waiting for the boy's father to get back to them.
The Risk of Serious Harm report was closed in January on the assumption by the Department of Communities and Justice that the Child and Adolescent Mental Health Service was following up.
The inquest heard there was no further intervention from a department or support service from that time up to SG's death in May.
Magistrate Kennedy made several recommendations largely aimed at improving communication between agencies dealing with vulnerable people.
"He was a 15- year-old boy carrying the burden of life experience that many adults would not know how to deal with," she said.
"Encouraging agencies to work together in such circumstances might increase overall engagement with mental health services by teenagers."
- Support is available for those who may be distressed. Phone Lifeline 13 11 14; Kids Helpline 1800 551 800; beyondblue 1300 224 636.
