THE mother of a Worcester teenager found dead in a field said her death could have been avoided. Liz Tyler made the comments following a serious case review into her daughter Jade’s care. The review highlighted a lack of co-ordination between the different agencies involved with 16-year-old Jade and criticised the resources available for vulnerable teenagers. The report, compiled by the Worcestershire Safeguarding Children Board – made up of representatives from several agencies which provide services for children, including health workers, education, police, probation and child protection charities – concluded: “Even as an adult, with such a level of vulnerability, the multi-agency processes should have afforded her safety and protection.” Jade was being treated for a mood disorder but when she turned 16 her mother found it increasingly difficult to care for her. Mrs Tyler, herself suffering from mental health problems, said: “It was not working out, she was fighting with her sister, staying out all the time and not coming home. “She would not live by my rules and she wanted to leave home.” The former Christopher Whitehead Language College student lived initially with friends while she waited for accommodation at the Malvern Foyer, a place for homeless teenagers to live. She planned to go to college in Malvern, but lost her course place because she could not afford to get there. As a result she lost her place on the Foyer waiting list, so was housed in a bed and breakfast. Unable to pay the rent from her Job Seekers Allowance benefit, Jade was evicted. The report states she was adopting an “increasingly risky lifestyle” and had attempted suicide on a number of occasions. Police were so concerned for her safety they placed her in police protection on two occasions Shortly before Jade went missing she was displaying odd behaviour and her sister Katie desperately tried to help. The teenager was eventually taken to Worcestershire Royal Hospital where she was seen by a doctor. The GP sought advice from the on-call psychiatrist and two workers from the emergency mental health service and Worcestershire County Council’s emergency duty team attended. By this time it was early on Saturday, December 27, and doctors decided the psychiatric assessment should be carried out later that day. Jade was sent home with her mother, but as they were leaving the hospital she disappeared. Her body was found 12 days later on Thursday, January 8, in a muddy field of Pershore Lane, Worcester. She had died from hypothermia. “If things had been done differently Jade would still be here,” said 40-year-old Mrs Tyler, of Carnforth Drive, Warndon, Worcester. “If she had been taken into hospital that night maybe, but they just didn’t want to know. “I know it is too late for Jade, but I would not like to see the same thing happen to anyone else.” Your Worcester News was handed a copy of the report by the Tyler family, but it is not yet due to be published, and none of the agencies involved will comment about specific points raised until it is. Instead, Gail Quinton, director of children's services for Worcestershire County Council, released a statement on behalf of the authority as well as West Mercia Police and Worcestershire Primary Care Trust. “All the agencies working with this young person and her family have met together regularly to review actions and to ensure lessons are learned to prevent any recurrence of such a tragedy,” she said. “There is a real commitment to embedding learning across Worcestershire and we have been working with the family to make sure their views have been taken into account. “All recommended actions will be implemented and regularly monitored.” General recommendations - Improve transition planning between children's and adult’s mental health services. - Improve referral processes between schools and Connexions for ‘vulnerable’ pupils. - Record checks made with the List of Children with a Child Protection Plan when a child attends A&E. - Explore the impact on children of caring for a parent with mental health needs. - Raise awareness of issues arising from working with youngsters with mental health needs. - Improve recording practices. - Improve staff supervision policies particlarly when working with families with complex needs. - Stress importance of sharing information and coordinating services between agencies working with the same family. - Improve how plans are reviewed when crises or changes of circumstances occur and/when an agency withdraws from the support network. - Clarify what procedures are expected of agencies by the Worcestershire Safeguarding Children Board when working with 16 and 17-year-olds - particulary when finding accommodation. - Review resources available for homeless 16 and 17-year-olds. - Review how young people are assessed, particularly out of hours. - Review how young people are reported as missing, including the police recording. - When mental health services are provided to an adult consider what impact there may be on any children living in the house and any services they may require as a result. - Ensure lessons learnt from this review are fed back to the Worcestershire Safeguarding Children Board’s Strategy Group and invite Jade’s family to contribute to its work. - Improve management, leadership and training to ensure all staff recognise and appreciate the potential vulnerabilities of 16 and 17 year olds. Worcestershire Primary Care Trust was asked to: - Review safeguarding procedures for sexual health services to ensure staff understand and recognise vulnerability in young people. - Ensure the out of hours service for children with mental health difficulties is coordinated so specialist advice is available at all times. Worcestershire County Council was asked to: - Ensure there are adequate arrangements within its emergency duty team to fulfil its responsibilities under the Children Act 1989. - Ensure appropriate assessments of risk are made and immediate action taken when staff attend urgent and complicated situations. - Adult and community services must review how it contracts out services. West Mercia Police was asked to: - Review its initial risk assessment processes for missing person’s enquiries to take account of information contained in police records.