The treatment and death of a teenage Aboriginal girl found electrocuted near train tracks in Adelaide is a "deeply shameful" situation, a coroner says.
Heidi Singh, 14, was found near a rail line in Adelaide's south in 2014 after a long history of self-harm, violent and aggressive behaviour and absconding.
In her inquest findings on Thursday, deputy coroner Jayne Basheer said the girl "died alone without ever knowing her own culture and community".
"She languished in emergency care without the assistance of a dedicated team within Families SA to focus on Aboriginal children in state care and the Aboriginal Child Placement Principle," Ms Basheer said.
"She died without the chance to be supported in her time of need by a loving foster family and without access to skilled therapeutic support.
"In my view, it is a deeply shameful situation."
Ms Basheer said the teenager started life in the most difficult of circumstances,
A few days after her birth she was relinquished by the biological mother into the informal care of another couple.
By age three she had been diagnosed with foetal alcohol syndrome disorder and by the time she was 13 both her parental figures had died and Heidi had been abandoned by all subsequent carers.
Her biological mother had also died of a drug overdose.
The coroner said despite the intervention of the children's mental health service, little was done to address the underlying causes of the girl's distress or change her disruptive behaviour.
Ms Basheer said her inquest also exposed the "silo" approach taken by government agencies involved in Heidi's case as they focused only on particular aspects of her life and care.
"There was a distinct lack of collaboration," she said.
But the coroner said whether or not the girl's death was preventable was a complex question and one she found not possible to answer with any certainty.
"One could argue there were many opportunities for intervention which could potentially have prevented her death," Ms Basheer said.
"The opportunities for intervention date back to early in her childhood and extend to the period during which Heidi was in the care of the minister."
However, the coroner ruled that despite the teenager being in a distressed and disassociated state when she ran away from an emergency placement and made her way to the railway line, her death was an accident and not a suicide.
In her recommendations, Ms Basheer called on the government to find a better way to manage the needs of children such as Heidi,
"I suspect that the answer lies in a wholescale paradigm shift, the abandonment of outdated models of care, early intervention programs and a significant financial investment in a new therapeutic model of care," the coroner said.
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Australian Associated Press