Bryn Melyn care fire report says girl's death 'preventable'
The death of a teenage girl in a fire at a Shropshire children's home could have been prevented, a report has said.
Kelly Button, 17, from Wolverhampton, barricaded herself in a bedroom and set fire to a mattress at Bryn Melyn Care Home near Ellesmere in December 2012.
The Walsall Safeguarding Children Board report said she had a history of such behaviour, making it "predictable" she would eventually cause harm.
It made more than 50 recommendations to the agencies involved in her care.
'Out of sight'
The report said the teenager had been brought under the care of Walsall children's social care in 2011 at the age of 15.
While describing Kelly as "bubbly", it went on to say she was "often extremely aggressive and had a lot of anger".
On the night of the fire, she barricaded herself into her bedroom by placing a mattress against the door after her carers denied her internet access, then set fire to the mattress.
An inquest two years ago ruled her death was accidental.
The serious case review criticised a number of agencies involved in Kelly's care, including Walsall Council, West Mercia Police and Shropshire children's social care, for their failure to coordinate her care which, it said, "indicated an almost 'out of sight, out of mind' culture".
There was no "robust review" of her care and she was moved around a number of different homes, often far away from her family.
"In view of the aggressive, violent fire-setting and risk-taking behaviour, which was consistently displayed by the young person it was predictable that she would eventually cause serious harm," the report said.
It outlined previous examples of Kelly barricading herself in rooms and setting fire to objects, including hospital treatment for the effects of smoke inhalation in May 2011.
The serious case review concluded a more co-ordinated approach, coupled with the possible use of secure accommodation, may have potentially prevented her death.
In a joint statement on behalf of Walsall Council and other agencies, the safeguarding board said "considerable improvements" had already been made.
"Each agency represented on the board has committed to taking the necessary actions to improve practice, including developing action plans focused on each of the recommendations," Robert Lake, chair of the board, said.