Wolverhampton girl could have been better protected
A serious case review into the death of a 13-year-old girl has revealed more should have been done to stop her killing herself.
Referred to only as child FJ, the girl was found hanging at her home in Wolverhampton on 29 June 2011.
A review by Wolverhampton Safeguarding Board said while her death was not preventable, agencies could have collaborated better to protect her.
They said all recommendations had already been implemented in full.
The review heard the girl had a history of self-harming.
In the months leading up to her death she had taken an overdose and cut her wrists, as well as written in her diary that she wanted to kill herself.
She was referred to mental health services, among other agencies, and the serious case review said staff had shown "undue optimism" after she was admitted to hospital.
The report found: "FJ was as clear as she was able to be that a return home would lead to a further suicide attempt."
It also said while there were "many examples of sound inter-agency work" there were also "'system failures" when it came to working together.
Alan Coe, chair of the safeguarding board, said: "Although the review did not conclude that FJ's tragic death was preventable, had best practice prevailed, the risk of further suicide attempts would probably have been better identified and led to a more collaborative effort to keep her safe."
The serious case review involved looked at work by the Black Country Partnership NHS Foundation Trust, Wolverhampton City Council, The Royal Wolverhampton NHS Trust, West Midlands Police, Wolverhampton City Primary Care Trust and FJ's school.
The report made 35 recommendations, including calling for better training for staff involved with young people who self-harm, improvements in record keeping and better information sharing between agencies.