Hospital staff criticised for not helping distressed 13-year-old after suicide attempts just months before she was found hanged

Hospital staff have been accused of failing a suicidal 13-year-old girl who hanged herself after they sent her home. Despite earlier attempts to end her life and her mother's desperate pleas, Chelsea Clark was discharged. A month later the grammar school pupil's parents found her dead in her bedroom.

Staff at New Cross Hospital in Wolverhampton had missed several opportunities to help the troubled teenager, a serious case review found. Chelsea, who attended Wolverhampton Girls' High School, had already tried to commit suicide. Her mother Margaret Clark told doctors she could not keep her daughter safe, but the schoolgirl was sent back to her home in Finchfield, Wolverhampton.

In May 2011 she took painkillers in a 'significant' overdose that left her in hospital for eight days.

Medics considered admitting her to a specialist adolescent unit but she was released without a customary pre-discharge meeting.

Just two weeks before she died on June 29, 2011, Chelsea told a school psychologist she had tried to harm herself after hearing voices in her head.

The review, by Wolverhampton Safeguarding Children Board, found 'a number of examples of individual sub-optimal practice' involving mental health staff, social and community services workers and the police. It said there was 'undue optimism' among mental health staff who dealt with Chelsea after her initial assessment on the day she was hospitalised.

The board concluded that 'had best practice prevailed, the risk of further suicide attempts would probably have been better identified' and that a 'more effective collaborative effort' could have been made to keep Chelsea safe. More than 30 recommendations have been made to the agencies involved to improve standards of care.

Identifying Chelsea as FJ, the review said she was 'lonely, helpless and stressed in the face of high levels of pressure from within her family.

It added: 'Though FJ's mood state seemed to vary she was fairly consistent in offering verbal and non-verbal indications that she would self-harm or worse if returned home.' An inquest into her death in September heard Chelsea may have suffered post-traumatic stress disorder from her 'stifling' home life. Mrs Clark told the hearing she had confiscated three mobile phones from her daughter and banned her from using social networks to stop her contacting her 14-year-old boyfriend.

The teenager ran away from home in the months leading up to her death and wrote suicidal thoughts in her diary.

Mrs Clark told the hearing: '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.'

The inquest heard Chelsea was found hanged after her mother had been out for a walk. Mrs Clark added: 'I went up but the door to her bedroom would not open … I put my shoulder to it and the door bowed. I could see that Chelsea was not at her desk or on her bed. 'I knew she was behind the door. I called for my husband to come up. He put a lot more force behind the door and kicked it in. We both fell in at the same time.'

The inquest heard that Chelsea left a suicide note but was described as being 'quite happy' at school.

A child psychiatrist told the hearing Chelsea was suffering from post-traumatic stress disorder brought on by 'what she regarded as her rigid upbringing'. Alan Coe, chairman of the Safeguarding Children Board, said: '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.'