CHILD protection and mental health services in Dorset have been urged to make changes after the tragic death of Rebecca Berry.

The Serious Case Review into the 15-year-old's death in 2014 made numerous recommendations to the Dorset Safeguarding Children Board, which is made up of representatives from local authorities, the NHS, charities and Dorset Police.

As well as urging better co-ordination between its partner agencies, the report identified a need for "better understanding" by professionals of the impact of lingering trauma from adoption, relationship break-ups and sibling violence on the mental health of young people.

Also, it urged the board to investigate whether demand on resources has had an influence on how cases are assessed.

The Daily Echo was unable to reach board chairman Rob Hutchinson on Friday, however in a statement he said: "On behalf of all the agencies involved, we would like to extend our heartfelt sympathy to Rebecca’s family and friends.

"There were a number of services working with Rebecca and her family in the months leading up to her tragic death.

"This in-depth review looks at whether anything could have been done differently and identifies lessons that must be learned by all involved.

"We are committed to supporting young people and their families and will do everything in our power to minimise the chances of such a devastating tragedy happening again."

The board was urged to "improve understanding and application" of the threshold for determining when vulnerable young people should be referred to social services, and also to investigate whether the "availability of resources" has affected the rate and take-up of referrals.

With Rebecca classified as a 'child in need' rather than in the more serious 'child requiring protection' category her claims were not taken as seriously as ought to have been the case, the review found, although it did not explain why this decision was made.

Again, the report called for an investigation into whether "demands on resources are playing a significant part in how children in need are provided with a multi-agency service", and also into whether the current process requiring parental consent for youngsters to access mental health services is "effective".

The review found that while practitioners from a number of agencies had tried to help Rebecca, the information about her case had not been coordinated using the existing Common Assessment Framework tool, and called on the board to do more to promote and monitor the use of such practices where appropriate.

More damningly, the review claimed there was "insufficient recognition, knowledge or understanding of the impact of sibling violence on the psychosocial development of children" among practitioners and that "limited action is taken to protect them or address their needs".

It called upon the board to consider outside expertise on the matter, noting that agencies in Dorset "do not record data around sibling violence".

Other lessons to be learned, identified by the authors of the review, are a need for greater integration of specialist adoption services into first response services, and greater recognition of the difference between "normal adolescent development" and behaviour "requiring specialist input".

They said: "Throughout this case, practitioners stated that [Rebecca] was 'no different from her peers' whereas the extent of the extremes of behaviour suggested that her functioning was outside normal expectations".

Also, they said: "In Dorset there have been two previous Serious Case Reviews where teenagers have died. Both exhibited confusing presentation with fluctuating moods but the depths (sic) of their despair was not recognised."

In this case the board was urged to investigate whether practitioners working with young people have sufficient support to identify this difference, and whether they are aware of existing support services.

The review identified areas where changes had already been made as a result of Rebecca's death.

These included clarifying the conditions under which school nurses should report their concerns to social services, as investigators found this was an area of confusion.

Also steps have been taken, the report said, to ensure front line professionals, such as nurses, GPs and social workers, who refer cases to mental health services are kept informed if those cases are subsequently closed, so they can ensure suitable support is available.

It heard it was "not uncommon" for such professionals to be "unaware that a case had been closed".

Dorset County Council, which is responsible for social services and QE School, and Dorset HealthCare, which is responsible for the CAMHS mental health services team, both declined to comment on the review when contacted by the Daily Echo.