- Chelsea Clark was admitted to hospital after taking painkiller overdose
- She told staff she would try to kill herself again if she was released
- Teenager found hanged at home in Finchfield, West Midlands in June 2011
Tragic: Chelsea Clark, 13, was found hanged at her home in July 2011 after struggling with depression
Grammar school pupil Chelsea Clark was found dead in her bedroom in Finchfield, West Midlands in June 2011.
She had previously spent eight days in hospital after taking a deliberate overdose, and told medics that she would try to kill herself again if she was sent home.
The teenager also told a school psychologist that she had cut herself after hearing voices, just two weeks before her parents found her hanged.
A 'serious case review' published yesterday by Wolverhampton Safeguarding Children Board found that hospital staff missed a number of opportunities to help Chelsea.
In spring 2011, the 13-year-old took an overdose of painkillers and spent eight days in a hospital which is not named by the report.
Doctors decided not to admit her to a specialist adolescent unit, and discharged her without a meeting to discuss her future care.
The decision came despite the fact that Chelsea 'was as clear as she was able to be that a return home would lead to a further suicide attempt', according to the report.
In the months leading up to her death, the schoolgirl ran away from home and wrote suicidal thoughts in her diary.
Vulnerable: The teenager was sent home by a hospital even though she said she would kill herself
Home: Chelsea's parents found her dead in her bedroom at their house in Finchfield, West Midlands
The review criticised 'a number of examples of individual sub-optimal practice' involving mental health staff, social workers and the police.
And it said a 'more effective collaborative effort' could have been made to keep Chelsea safe, 'if best practice had prevailed at all times'.
The review, which identified Chelsea only as 'FJ', made more than 30 recommendations to improve care and prevent a repeat of the tragedy.
It said: 'In essence, whilst apparently showing only limited signs of depression, FJ emerged as feeling lonely, helpless and stressed in the face of high levels of pressure from within her family.
'Observation of self-inflicted scarring on arms and abdomen by the GP and hospital respectively suggest also that FJ had found coping with her life more difficult than was obvious to others.'
An inquest in September heard that Chelsea, who attended Wolverhampton Girls' High School, may have suffered post-traumatic stress disorder from her 'stifling' home life.
Struggles: Chelsea, pictured with a former teacher, had made a number of suicide attempts before her death
Pupil: The 13-year-old was studying at Wolverhampton Girls' High School at the time of her death
The girl's mother Margaret told the hearing that she had confiscated three mobile phones from her daughter and banned her from using social networks in an attempt to stop her contacting a 14-year-old boyfriend whom she met online.
'I was the baddie,' she said. 'She was resentful and angry towards me. It began to build up. I suppose she hated me.
'We all tried to talk to her about it but towards the end it was like talking to a stone wall.
'I would be the one who was saying, "You're not going down the road, you're not mixing with those teenagers." She really began to hate me because I was the one who had to make the stands with everything.'
Mrs Clark also described the horrific moment she and her husband found Chelsea dead in her bedroom after she returned home from a walk.
The teenager left a suicide note, but had been believed to be 'quite happy' at school in the days leading up to her death.
The coroner recorded a narrative verdict, saying it was 'not entirely clear that she intended to end her life'.
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