The sister of a 13-year-old girl who took her own life at a children’s home hundreds of miles from her family said the death had left a ‘hole in our lives that will not be filled’.

The girl, who we are not naming, died after hanging herself at the facility in Wales in 2013. She had a history of self-harm although social workers believed her repeated attempts at tying ligatures around her neck were ‘attention seeking’.

In a serious case review published last week, Oxfordshire’s Safeguarding Children Board charted a series of failings in the care of the girl – named in the report only as Child R.

The review warned there continued to be a shortage of children’s home placements, resulting in a ‘possible increased risk of harm when children are placed far away from home’.

Reacting to the findings of the case review, Child R’s sister told the Oxford Mail: “I hope [the authorities] feel the sense of pain and the hole she’s left in our lives that will not be filled.

“A serious case review, a report, a prosecution and all of that may do some good in the future for young people in Oxfordshire and we hope it improves things.

“But that won’t bring my sister back. It won’t fill the gap that’s she’s left.”

‘Child R’ and her siblings were first placed in foster care in March 2005 after concerns about physical, sexual and emotional abuse and neglect.

They were returned to their parents although court proceedings were launched later that year over ‘escalating concerns’ about the care the children were receiving.

By 2010, the girl’s school raised concerns about her self-harming and running onto a nearby railway line. An assessment by child mental health services concluded she was not depressed or showing signs of self-harm.

In autumn 2010, she reported that she had suffered sexual abuse at the hands of a close family member. Police interviewed her twice but concluded that there was insufficient evidence to secure a conviction and dropped the investigation.

The serious case review authors said: “The episode left Child R feeling that she had not been believed and worried that she had not been able to protect her siblings.” The police investigation ‘fell short of the standards that would be expected today’, they said

The following year, in June 2011, a family court judge decided on the balance of probabilities that Child R had been sexually abused and suffered neglect.

She was placed with foster parents but, after taking an overdose in 2012 when she was just 13-years-old, was admitted to a psychiatric unit.

The girl was moved to a specialist facility in Wales, run by a provider known to her treating psychiatrist and Oxfordshire’s children’s social care department that had another young person placed with them.

She was said to have settled into the home well and was happy. Although there were fewer self-harm incidents, they continued to happen regularly. She was twice admitted to hospital after swallowing glass in December 2012 and, later that month, was taken to A&E after cutting her elbow.

There was no specific suicide prevention plan in place during her stay at the children’s home. Although plans did address risks like clothing, which could be used as a ligature, they did not specifically consider possible ligature points in the home or her room. The girl used the same ligature point to take her own life as she had two days before.

The serious case review report said the risk assessments should have been scrutinised when social services commissioned the placement at the home.

And the report’s authors chronicled confusion between the residential care company and the girl’s social workers about what they meant by 2:1 care. It was assumed by some to mean she was observed throughout the night, although this was not the expectation of care home managers.

“On the night of her death, the expectation of Oxfordshire children’s social care was that since there had been a previous suicide attempt that day, staff would have consulted with [child mental health services] and a staff member would have carried out continual observations through the night,” they said.

On the night of her death, February 26, 2013, staff took away her blanket and the girl settled into bed at 10pm. Records showed staff ‘monitored from the landing’ and went to bed at around 11.30pm. The girl was found dead in her room the next morning.

Derek Benson, independent chairman of the Oxfordshire Safeguarding Children Board, apologised for the delay in publishing a serious case review. It was ‘held up’ by a criminal investigation that was later shelved and a prosecution that, in 2020, saw care firm Bryn Melyn Care Limited fined £600,000 for health and safety breaches.

“We have been able to draw on what happened to Child R to identify where real changes to practice in Oxfordshire have been implemented,” Mr Benson said.

“This includes how families are helped at an earlier point; how services listen to and respond to children when they tell us their very serious concerns; how children are supported when living in a residential placement a long way from home; the very detailed work that is needed to prevent self-harm and suicide; and how we check those services are doing what they say they will.

“Considerable improvements have been made in Oxfordshire since Child R’s death in 2013, but we will never be complacent and welcome new recommendations formed around our current safeguarding systems, to reduce the risk of such a tragedy happening again.”

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