Written by an independent author, the review recommends ways in which agencies should work together more effectively to better safeguard children.
Child FJ, as she is referred to in the review, died as a result of hanging on 29 June, 2011. In the months leading up to her death, she had taken an overdose and revealed a history of self harming and had been referred to agencies for help.
As a result of the review, an action plan detailing more than 30 recommendations for the agencies involved was developed. These recommendations, which address a number of issues including how information is recorded and shared, training and new practices for working with children who self-harm, have subsequently been implemented.
Alan Coe, Chair of Wolverhampton Safeguarding Children Board, said: "On behalf of Wolverhampton Safeguarding Children Board and the agencies involved in this tragic case, I would like to express our deep sorrow to the family for the loss of a lovely, talented and much loved daughter.
"The Serious Case Review has looked closely at everything that happened to see what could have been done differently.
"Although the review did not conclude that FJ's tragic death was preventable, had best practice prevailed the risk of further suicide attempts would probably have been better identified and led to a more collaborative effort to keep her safe."
Six agencies were involved in the Serious Care Review, including the Black Country Partnership NHS Foundation Trust, Wolverhampton City Council, The Royal Wolverhampton NHS Trust, West Midlands Police, Wolverhampton City Primary Care Trust and FJ's school.
The Serious Case Review Panel identified a total of 35 action points, which the agencies involved have implemented in full.
These include training to improve professionals' response to young people who self harm and to highlight the importance of early interventions, and improving record keeping and information sharing to develop a more coordinated approach between agencies which better meets the needs of children.
Steps have also been taken to ensure that agencies are made aware when young people are admitted to A&E because they have self harmed, and the discharge process has been improved to ensure professionals, the family and the young person are clear about ongoing support.
Other recommendations sought to address the concern that not enough weight was placed on what FJ was saying, with agencies now required to give sufficient regard to the young person's voice.
Pupils with complex mental health issues can now receive counselling at school, and parents have been invited to support classes to find out more about cyber bullying and how they can protect their children when they are online.
Mr Coe said: "I would like to give my sincere thanks to the family of FJ for working closely with us at what remains a very difficult time for them all.
"While it is impossible to say that an incident like this could never happen again, the actions that the Board has taken will go some way to making sure that we keep our children and young people safer in the future."
The Executive Summary, together with the Action Plan, can be found on the Wolverhampton Safeguarding Children Board website, Type=links;Linkid=3006;Title=Serious Case Reviews;Target=_blank;.
What is a Serious Case Review?
A Serious Case Review is initiated if a child has died, including death by suspected suicide, and abuse or neglect is known or suspected to be a factor in that death. Its purpose is 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, to identify what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result, and, as a consequence, improve intra and inter agency working and better safeguard and promote the welfare of children.
- released: Monday 4 November, 2013