A TEENAGER who died after setting fire to herself told an advocate in the months before her death: "No one listens anyway".

Rebecca 'Rebe' Berry self-immolated in the garden of her family home in Edmondsham, near Verwood, on December 1, 2014.

Now a serious case review has found that agencies involved with the 15-year-old failed to coordinate their responses, which led to a lack of understanding about her level of distress.

A report of the review was published by the Dorset Safeguarding Children Board on Friday, April 29, after a four-month delay.

Authors considered the last year of Rebe's life, during which time she openly expressed a wish to die and claimed that she had run away from home and slept in a tent in the woods.

They concluded that "the depth of [her] despair was not comprehensively recognised or understood".

Among the agencies highlighted in the report are the Child and Adolescent Mental Health Service (CAMHS) and Rebe's school, QE in Wimborne.

The report also considered Rebe's relationship with her brother, who allegedly had a "history of violence" toward both Rebe and her adopted mother, Gill Taylor.

Rebecca had sought help but agencies who attempted to contact Ms Taylor to offer support failed to receive a reply, the review found.

Authors wrote in their report: "Of critical importance was the question of whether the family were working in an open and honest way with professionals, and whether the family were engaged in meaningful cooperation."

Rebe's feelings were 'rationalised' by the professionals she did see, many of whom "denied her reality" and struggled to differentiate between "the normal mood swings of adolescents and behaviours that indicate significant psychological trauma".

None of those involved thought to open a Common Assessment Framework, potentially as the result of "inconsistent messages" about its use and implementation.

This may have allowed representatives from different agencies to work together.

Children's Social Care (CSC)

In July 2014, CSC received a referral from police after it was reported that Rebe's stepfather Scott Taylor had sexually abused a young woman not connected with the family. He was later acquitted following a trial at Bournemouth Crown Court.

While the investigation was taking place he was asked to leave the family home and comply with a 'contract of expectations'.

Rebe believed her stepfather protected her from her brother, who had a "history of violence" towards both Rebe and Ms Taylor.

Rebe's social worker and the practice manager remained concerned about the her safety.

But a more senior manager challenged the decision and took the view that sufficient safeguards were already in place, meaning that the case should be worked under a lower threshold for intervention as a 'child in need'.

The authors of the report said this decision "resulted in unintended consequences" and had a "detrimental impact on how [Rebe's] needs were understood and met".

Child and Adolescent Mental Health Service (CAMHS)

Rebe's GP first made a referral to CAMHS in the early part of 2014.

This followed contact from a concerned nurse at QE School.

After receiving the letter, CAMHS categorised the case as 'non-urgent' and a letter was sent to Rebe's adoptive mother, Ms Taylor, asking for her to make contact with the service.

No response was received, and the case was closed.

In September of that year, Rebe herself asked to be referred to CAMHS.

Once again, a letter was sent to Ms Taylor and no response was received.

On that occasion, a manager who recognised Rebe's name followed up with a phone call and offered a provisional appointment.

The meeting was scheduled for a week after the teenager's death.

In line with existing protocols, Rebe - as a child who had been adopted - should have been assessed with a specialist worker.

This was not done.

Ms Taylor told the review that, in her experience, it was family and friends who could help Rebe.

Authors of the report said: "She held onto a belief that the love she showed to her children would ultimately win through."

Children's advocate for Action for Children

Ms Taylor had requested an independent advocate for Rebe at a meeting in September 2014.

One was not provided until November of that year, just a month before Rebe's death.

This was due to a high volume of demand for such services at the time.

Rebe told the advocate of her wish to die, and gave her permission for her views to be shared at a 'child in need' meeting.

However, she added: "No one listens anyway". When the advocate shared Rebe's thoughts at the meeting, they were 'rationalised' as part of her 'up and down' state, the report says.

QE School

In September 2014, a 'child in need' meeting was held.

Representatives from Rebe's school, QE in Wimborne, were invited but did not attend.

In late November 2014, Rebe's boyfriend, who cannot be named, broke up with her.

Teachers recognised the "extreme nature of [her] distress was unusual" but were unable to "contain [it]" and Rebe was sent home.

Staff at the school were unaware of the involvement of CSC or the complex issues at home as there was no representative at the 'child in need' meetings.

In addition, there had been "no effective information sharing" between the school nurse and the school in respect of her needs.

As a result, the incident wasn't reported to CSC, which "fell below expected practice standards".

What is a serious case review?

A serious case review takes place after a child has been killed or seriously injured and abuse or neglect is thought to be involved.

The process aims to establish what lessons can be learned about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children, identify what must change and better safeguard and promote the welfare of children.

Results are published through an authority's Safeguarding Children Board and must be made publicly available.

Inquest into Rebecca's death 

A coroner recorded a narrative verdict into Rebe's death last year which said: "She died as a result of self-immolation but there is doubt as to whether she intended her actions would result in her death."

He added: "I do not think, at the end of the day, that she had thought this through."

A post mortem examination concluded Rebe had died of inhalation of smoke caused by self-immolation.

Her body was discovered during the evening of December 1 2014 when Ms Taylor called Rebe in to watch a television programme and realised she wasn't in the house.

Tealights were seen glowing from a den in the garden in which Rebe had created a shrine following the death of her kitten, Honey.

Ms Taylor found Rebe's body alongside the tealights.

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