A “concerning picture” was developing about the welfare of Amber Peat more than a year before she was found hanged, a coroner said.
The body of the 13-year-old Mansfield girl was found in June 2015, three days after she went missing from her home, following a row with her mum over household chores.
An inquest in Nottingham heard that Amber’s GP had raised concerns about her behaviour, in January 2014, because she had run away from home, was performing poorly at school in Tibshelf, and she had a new stepdad with mental health issues.
Joanne Robinson, manager of the Tibshelf Multi-Agency Team (MAT) in Derbyshire, said two workers visited the family after Amber went missing in January 2014.
But a full Common Assessment Framework (CAF) - to assess the needs of a child or family, if they agreed to work with the MAT - was not started.
“Why wasn’t a CAF completed shortly after the home visit?” asked assistant coroner Laurinda Bower.
“I can’t answer that fully,” said Mrs Robinson. “We were working towards a CAF with the school.”
“Even now you are still unable to explain why that didn’t happen,” said Miss Bower.
“The family just wanted help with their home and housing conditions and to work with Amber about her behaviour,” Mrs Robinson said.
“The GP had asked you to look at family dynamics, but that question doesn’t appear to have been asked. Was it overlooked?”
A youth worker did one-to-one sessions with Amber, to give her coping strategies and help her communicate better with the family, said Mrs Robinson.
A Serious Case Review, following the teenager’s death, found that the package of care was not a standard one, and was “led more by Amber’s wishes”.
Concerns were again raised, on March 7, 2014, when Amber reported being left at home to wash up while her parents went out, and, escaping through a window, she ran away from home.
She told the youth worker that her parents had told her: “What goes on in this house stays in this house.”
The assistant coroner asked: “Would you follow it up with the parents?”
“A lot of this is confidential between the child and the youth worker,” said Mrs Robinson. “There is no note in the records about that specific point.”
“You seem to say a lot “There should have been a note of that but there isn’t,”” said Miss Bower. “Is that acceptable practice?”
Mrs Robinson said: “We were very much in our infancy when we were first formed. It just wasn’t recorded. There were lots of other conversations. We were working with Amber to help her with coping strategies. A lot of children say things when they are up and down. We wouldn’t go back to mum every time Amber said something.”
A midwife also said that Amber’s dad had taken an overdose of his medication in February, that her mum had a history of depression, but wasn’t on medication, and the family were thinking about moving house.
The assistant coroner asked what the MAT team did with this information, adding that a Serious Case Review said this should have been a trigger for an Early Health Assessment.
“We were still doing one to one sessions with Amber,” Mrs Robinson said. “We hadn’t got enough information from the family.”
“You never asked them if they would like to engage with the CAF process,” the assistant coroner said. “It was never offered. It simply didn’t happen, did it?”
“That’s what we say - if it’s not been recorded it’s not happened.”
The inquest heard that Amber ran away from home after an argument, on April 4, and when her parents were contacted, they said they could not come and fetch her as their dog was in labour.
“Was it appropriate for the school to consider referring Amber to social care?” asked the assistant coroner.
“It wouldn’t have met the threshold. It was always a consideration. We needed a lot more information on the emotional side of that,” said Mrs Robinson.
“She had some good days and bad days. She improved at one point at school and deteriorated at another. We have no toolkit to assess emotional harm. We have to gather as much information as possible and then put the evidence to social care and they make a decision. It makes it difficult to assess not just in this case but in all cases.”
“Between January 2014 when you received the referral and June 2014, when the family indicated they were leaving, all that happened was one to one sessions,” said the assistant coroner.
“Do you think there was missed opportunity to do more work with Amber and her family?”
“With hindsight we could have pushed and pushed,” said Mrs Robinson. “They could have cooperated. But we could have started and the family could have said no.”
“But they were denied that opportunity because it was never offered,” said the assistant coroner.
The inquest heard that after the family planned to move to Mansfield, members of the MAT team only made one, unannounced visit, to their home for consent to transfer their notes to their counterparts in Nottinghamshire.
Solicitor Phillip Turton, acting for Mrs Peat, asked Mrs Robinson: “You did nothing more about obtaining their consent?”
“There was nothing on record.”
“You did nothing didn’t you?” Mr Turton said.
The inquest continues.