Social services 'missed 11 opportunities' to intervene with Amber Peat

An inquest at Nottingham Council House heard that both Nottinghamshire and Derbyshire authorities failed to correctly act on a number of opportunities which could have led to better intervention for the teenager.

Social care expert Doctor Cath Connor said that "on the balance of probability", it was likely that Amber would not have taken her own life if social services had been made aware of her ordeal.

Assistant coroner Laurinder Bower identified "at least 11 missed opportunities where social services could have intervened", suggesting that if a number of opportunities had been taken there "could have been" a different outcome.

This includes a number of occasions where social services could have triggered a Common Assessment Framework (CAF) based on Amber's behaviour in order to assess whether she required intervention.

The coroner also suggested that social services "should have acted" on the behaviour of Amber when she went missing in January, February and April 2014.

She pointed out that, on each occasion Amber went missing, the local authorities "failed to act on national guidelines" which require 1-1 interviews to be conducted within 72 hours of the child's return.

Speaking at the inquest, she said: "There were a number of missed opportunities for a CAF including in January 2014 when a GP made a referral to Derbyshire's social services for an assessment on the family dynamic.

"It is also clear that when she went missing in January 2014 the social services did not follow a pro forma, did not visit her home within 72 hours of her return and did it with her mother present, so questions were not asked about why she went missing.

"In February 2014 she again was not asked upon return why she went missing, and in April there was no statutory meeting within this period.

"This poses an immediate risk and lack of concern for a child repeatedly running from home, and that there was a complete lack of protocol between January and April 2014.

"There was plenty more in formation that the professionals should have been made aware of.

"Amber was never spoken to about the possibility of her taking her own life, there was a focus on her behaviour but not from why she was acting on it."

The inquest also heard how the 13-year-old was seen strangling herself with ties and scarves, but that the incident was not reported "until after her body was found".

It was suggested by Dr Cath Connor that, if intervention was in place "at the time of this incident", it is likely on the balance of the probability that she "would not have killed herself".

The inquest also heard that different organisations failed to speak to each other about their concerns, and so a 'bigger picture' could not be realised.

"This suggests to me that this isn't individuals failing to work to the protocols but that there was a complete lack of protocol during January, February and March, 2014", Ms Bower added.

The inquest continues.