Seren Bernard death 'might not have been preventable'
The death of a 14-year-old girl under care of social services might not have been preventable even if more steps had been taken, a serious case review says.
Seren Bernard's body was found in Milford Haven, Pembrokeshire, in April 2012 but police ruled out crime.
Her mother Sarah Pollock complained to an ombudsman after the death claiming her concerns and views were ignored.
The Local Safeguarding Children Board which published the report said the death of any child was a profound loss.
The review, in which Seren was referred to as Child M, was written by an independent author provided by the British Association for Adoption and Fostering.
'Benefit of hindsight'
It said when she died she was settled in a foster placement that seemed to be meeting her needs well and was where she wanted to stay.
It added: "Following her attempted suicide in September 2011, Child M's vulnerability was such, and research regarding suicide would indicate, that a further attempt on her life was a possibility.
"However, in the days prior to her death, her mood is recorded to have lifted and her behaviour gave no indication that she was contemplating suicide.
"It must remain uncertain whether there were any steps that, if taken, would have prevented Child M's death."
The report said there were points, with the benefit of hindsight, at which different actions could have been taken by all agencies involved with Seren while making several recommendations for improvement.
These include a call for better multi-agency planning and co-operation, and to offer foster carers training to identify self-harm and suicide risks.
A spokesperson for the Local Safeguarding Children Board said: "The death of any child is a profound loss and all the professionals involved feel a deep sympathy for the child and her family.
"Lessons can always be learnt from these tragic events and all agencies on the Local Safeguarding Children Board are fully committed to implementing the recommendations made."
Ms Pollock, from Haverfordwest, has yet to comment on the review, saying she wants to take time to read it and speak to her legal advisors.
Following Seren's death in 2012, Ms Pollock told BBC Wales she used to be close to her daughter and described her as a grade A student who loved sport.
She said that about two years earlier Seren started behaving aggressively.
Ms Pollock said her daughter started smoking, drinking and playing truant. Seren's mental state had deteriorated, she added, and she tried to get counselling for her.
Ms Pollock says: "Her escalating behaviour was really attitude towards others, aggressive, which was why I requested the counsellor."
Seren rejected her, she said, and claimed she did not want to live with her mother on the grounds that she was aggressive.
"It was easy to see for everybody that this was a child going down the slope," Ms Pollock said, but she does not believe that she as her mother was the problem.
Ms Pollock said her daughter "didn't like the rules and the boundaries that were being put down" about such behaviour as smoking cannabis and drinking alcohol.
Following Seren's death Pembrokeshire council referred the matter to the Pembrokeshire Local Safeguarding Children's Board saying a child's death was "a matter of great concern and sadness" in all circumstances.