Erin Jones: Damning report over Ceredigion teen's death
A teenage heroin user who died in a shelter for homeless people in Ceredigion was let down by the authorities, says a report.
Erin Lluan Jones, 17, died after taking heroin in Borth, near Aberystwyth, in 2009.
Due to her age and the circumstances of her death, Ceredigion Local Safeguarding Children Board (CLSCB) carried out a serious case review.
Ceredigion council said lessons had been learned.
It is one of five serious case reviews that have been carried out by (CLSCB) into the deaths of four children in Ceredigion and a serious injury to a child.
The review studied a period of Erin's life from 5 November 2002 when she was aged 11, to her death on 4 April 2009.
Barrister David Spicer, who has been involved in considering the circumstances surrounding the deaths of more than 100 children, was appointed to act as the report's author.
Mr Spicer's report, which referred to Erin as Child Z, said her parents separated in 2002 and she moved with her mother to a different town.
She found this very difficult to accept, her behaviour deteriorated and she was beyond the control of her parents.
The report said Erin was persistently involved in criminal activity, found away from home drunk and was under the influence of drugs.
The report added that it was clear from an early age until she died that Erin was constantly a victim of sexual exploitation and other offences by men in their 20s and 30s.
Erin was eventually sent to a young offenders institute - twice in 2006 and again in 2008.
'Judgements not sound'
A year earlier in 2007 Ceredigion social services department closed her case because she was uncooperative.
The report said: "Inquiries and assessments that were carried out by Ceredigion social services department did not satisfy legal or guidance requirements and did not sufficiently consider the background of the family and the environment in which Child Z had been living.
"Other agencies did not insist that interagency processes were followed or contribute. Judgements were not soundly reached and responses were not coordinated and did not reflect the risks of very serious harm and abuse."
The report added that Erin was permitted or required to live in circumstances which would have been judged to be "unsafe" if proper inquiries had been carried out.
"Significant involvement of the youth offending service and drug and alcohol abuse agencies failed to impact on her behaviour and exposure to serious risk until the period immediately before her death," the report said.
However, the report said working with Erin and her family was "extremely difficult and stressful", and that it was rare that effort and commitment led to any improvement.
But it concluded that if procedures had been consistently followed, if inquiries and assessments had been more thorough, judgements more soundly reached, and interagency arrangements better coordinated, it was likely they would have made an impact on Erin's circumstances.
Ceredigion council said: "The purpose of undertaking a serious case review is to ensure that all agencies previously involved with the young person consider any action they have taken and, if necessary, review working practices in order to improve the services to families living within the area.
"All agencies were well aware of the human tragedy that was involved in each and every case and our sympathies lie with the families who are mourning the deaths of loved ones.
"Despite considerable resources issues, all agencies were committed to ensure that if there were lessons to be learned, they would be identified and systems put in place to address them."
At an inquest into Erin's death as a result of inhaling vomit in October 2010, Ceredigion's coroner returned a verdict of misadventure.