A report into the death of a 14 year-old girl while under the care of Pembrokeshire County Council has been published.
Seren Bernard – who is referred to as Child M in the report - was in foster care at the time of her death, in April 2012.
Seren took her own life.
The summary, which has been published on the Pembrokeshire County Council website, was written by an independent author provided by the British Association for Adoption and Fostering.
The review makes several recommendations for improvement, but concluded that it would remain uncertain as to whether there were any steps that, if taken, would have prevented Seren’s death.
Seren’s mother Sarah Pollock has previously complained about the way in which social services had handled her daughter’s case.
The summary details Seren’s movements between homes in Pembrokeshire, the midlands and Cornwall, instances of her running away from home and refers to a previous suicide attempt in September 2011.
It says that Seren had made allegations about drug-taking in her family and alleged that her mother had hit her.
In January 2012 Seren made an allegation of rape prior to becoming a looked after child.
The allegation was withdrawn by February 9th 2012 but the report is critical of the delay taken to investigate the complaint.
The lessons to be drawn from the case says: “Delays in carrying out police inquiries, where allegations of serious sexual assault/abuse have been made, must be avoided. Delay makes retraction of the allegation almost inevitable. The police should ensure that staffing and management levels are responsive and sufficient to meet this need. The police revised their procedures in July 2013 to address this concern.”
The summary adds: "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 says that with the benefit of hindsight there were a number of different actions that all agencies involved with Seren could have taken.
“There could have been better multi-agency co-operation and planning in this case, as they are key factors in working with high risk children and young people, particularly where there has already been a serious traumatic incident”.
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.”