Amber Peat: 'Opportunities missed' to help hanged girl
Opportunities were missed to help a 13-year-old girl who was found hanged, an inquest has heard.
Amber Peat was found in bushes three days after she walked out of her home following an argument about chores.
Assistant coroner Laurinda Bower said 11 occasions for authorities to provide "some sort of assessment" of Amber and her family had been identified.
Two councils and Amber's former school said they have made changes to policies following her death.
Nottingham Coroner's Court heard Amber and her mother had a consultation with a GP because of "behaviour issues", leading to a referral to a "multi-agency team" (MAT) run by Derbyshire County Council.
Amber was visited by a MAT staff member after running away from home in January 2014, but similar statutory visits were not carried out after further incidents that year, which were also not reported to police.
Amber moved to Queen Elizabeth's Academy in Mansfield, Nottinghamshire, with her family in June 2014, but not all details were shared when they moved between counties.
On two incidents staff at Queen Elizabeth's called the Nottinghamshire multi-agency safeguarding hub (MASH) to raise concerns over Amber, the inquest heard, but not all the information held by the school was relayed over the phone.
Cath Connor, who is conducting a serious case review into Amber's death, told the court there were several opportunities missed by schools and agencies in Derbyshire and Nottinghamshire to share information about Amber, which could have resulted in a referral to social care.
She said the Derbyshire MAT and Amber's schools may have had "false reassurance" that their support for the family was working, and said it was "surprising" teachers at Queen Elizabeth's did not know about two incidents where local pupils had seen Amber in parks with items of clothing tied around her neck.
Representatives from Derbyshire County Council and Nottinghamshire's MASH said they had improved their record-keeping process and staff training to ensure relevant information is shared between agencies.
Helena Brothwell, who became principal of Queen Elizabeth's in 2016, said she is confident the school now has "robust and secure" safeguarding procedures in place.
Dr Connor's serious case review into how the authorities handled the case, which is being conducted by the Nottinghamshire Safeguarding Children Board, is due to be published following the conclusion of the inquest.
Ms Bower concluded the evidence sessions for the inquest, and a verdict is expected to be returned on 22 February.