A suicidal 13-year-old girl was discharged from hospital despite pleas from her desperate mum. A month later Chelsea Clark's parents found her hanged in her bedroom.
Now a serious case review has found that staff at New Cross Hospital in Wolverhampton had missed several opportunities to help the teenager, who had been suffering from 'post-traumatic stress disorder because of her rigid upbringing'.
The review heard that Chelsea had already tried to commit suicide and her mum Margaret told doctors she could not keep her daughter safe, but she 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. Doctors considered admitting her to a specialist adolescent unit but she was released without a customary pre-discharge meeting.
Just two weeks before she died, 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.
A child psychiatrist told the hearing Chelsea was suffering from post-traumatic stress disorder brought on by 'what she regarded as her rigid upbringing'.