A traumatised 13-year-old who took his own life died despite the "very good job" done by his foster mother, a coroner has found.

In March, coroner Graeme Irvine adjourned the child’s inquest, expressing "real reservations", to allow Hertfordshire County Council, who placed him in her care, to consider a formal review.

However, concluding the inquest on July 19, after the council decided against a review, he said there was no "gross failure" and that it was not "probable" the suicide could have been prevented. 

George King was placed with east London foster carer Kathy Sweeney by the county council in 2018 and Irvine said his "overwhelming impression" was that he "blossomed" in her care.

Despite settling well in his new home in Romford, George took his life on November 1 last year, the same day he told Ms Sweeney he had attempted suicide previously but claimed he would not try again.

Coroner Irvine’s concern at the hearing in March was that Ms Sweeney’s decision to believe him and seek support the next day, a Monday, rather than immediately was "flawed".

Concluding the inquest this week, he said: "I do not say that everything was done perfectly but neither do I characterise Ms Sweeney’s actions as a gross failure.

"It is of course easy to say it should have been escalated to mental health professionals but I have to consider whether Ms Sweeney’s decision not to do so could have had more than a trivial [impact].

"It’s possible taking George to A&E could have… saved or prolonged his life but it’s also possible the psychiatric nurse would not have taken any steps and George would have been returned home, where a similar situation could have occurred.

"My overwhelming impression of George’s placement with the Sweeney family was of a safe, welcoming place of love. George blossomed while under Miss Sweeney’s care."

The coroner continued: "Let us not forget, George was a traumatised child with a very difficult relationship with his birth family. By any metric, his placement had improved his quality of life.

"I do not want her to confuse anything I said in this inquest… it’s very clear to me she did a very good job. 

"Losing a child in such shocking circumstances is frankly inconceivable to me as a coroner and a father and she’s very much in my thoughts."

George was found in his bedroom by Ms Sweeney's son-in-law while she was out of the house. He told the court previously he was told about George’s confession but allowed him to be alone because he appeared to be behaving normally.

At the hearing in March, Ms Sweeney told the court: "He was distressed because memories [of past abuse] were invading his head… I think that’s because he was so settled that he mentally let his guard down.

"I did not believe he was in any danger at that time, I believed the danger had passed. After the conversation, he just seemed to be his normal self.

"I sent a text to my social worker and said I would be calling her in the morning so we could arrange some support for him."

Coroner Irvine found George died from suicide but added that he was considering writing a report on how Hertfordshire County Council and Integrated Fostering Services, also involved in his care, could prevent similar incidents in future.

If you or someone you know if struggling with your mental health, you can get help

Samaritans operates a 24-hour helpline every day of the year on 116 123. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org

Rethink Mental Illness offers practical advice and information for anyone affected by mental health problems on a wide range of topics including treatment, support and care. Phone 0300 5000 927 (Mon-Fri 9.30am-4pm) or visit rethink.org.

Mind offers mental health support between 9am and 6pm, Monday to Friday. You can call them on 0300 123 3393 or text them on 86463.

Campaign Against Living Miserably’s (CALM) helpline and webchat are open from 5pm until midnight, 365 days a year. Call CALM on 0800 58 58 58 or chat to their trained helpline staff online.