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19 March 2019, 14:25 | Updated: 19 March 2019, 14:27
The death of a 13-year-old girl found hanged after a family argument "could not have been predicted", a serious case review has concluded
Amber Peat's body was found three days after she went missing from her home following a row with her mother over household chores.
The review suggested the teenager believed "she was to blame for many of the difficulties within the family", while a lack of planning led to gaps in the care she received.
Despite discussing her problems with two of her previous schools and with a youth worker, practitioners admitted their understanding of Amber's life was very limited.
The review suggested the family frequently moving house, a lack of recording in primary schools, a failure in following policies and procedures, and a weakness in transferring information led to the lack of communication between agencies.
At an inquest into Amber's death in February, assistant coroner Laurinda Bower recorded a narrative conclusion, suggesting agencies had missed 11 opportunities that could have prevented the youngster's death.
The coroner found as a fact the teenager had to scrub the floor until 1.30am and her stepfather had forced her to wear a "ridiculous" outfit to school to humiliate her.
Amber's mother Kelly Peat and stepfather Danny Peat insisted the accusations were lies but were described as "not concerned in the slightest" about Amber's welfare by the coroner.
The couple decided to go shopping, have the family car washed and have tea before calling police almost eight hours after the teenager stormed out of her home in Bosworth Street, Mansfield, Nottinghamshire on May 30 2015.
Although up to 400 police staff were involved in the search for Amber, her body was only found on June 2.
In the conclusion of the report, its authors said: "This review established that while there were concerns for the emotional well-being of (Amber), it could not have been predicted that she would take her own life. "
The review also said "domestic abuse" between her biological father and mother, which was reportedly witnessed by the children, may have influenced Amber's "needy" behaviour.
Chris Few, independent chairman of the Nottinghamshire Safeguarding Children Board, said: "We owe it to Amber to learn from what happened and Nottinghamshire Safeguarding Children Board commissioned an independent serious case review to examine what would lead to improvements in the way that agencies work to keep children safe.
"Action was commenced to address learning from the review as soon as it was identified and extensive work has been undertaken to ensure that safeguarding systems are as robust as they can be."