Lessons learned after Dana Baker tragedy

They insist that since the tragedy there had been a reduction in the turnover of social workers, easier access to mental health services and additional support for fostered children in education.

Guidance on suicide prevention and improved communication and working between agencies are also among the recommendations acted upon from a serious case review carried out following the schoolgirl's death.

Yesterday, Worcestershire coroner Geraint Williams said there had been 'serious systemic failings' in the care of the 16-year-old, who hanged herself from a tree in Kidderminster in 2011.

Speaking at the conclusion of her inquest, Mr Williams found systems were in place to protect Dana, but agencies did not abide by them and that arrangements set up for her were 'largely compartmentalised'.

This, he said, led to inadequate communication between agencies and individuals.

But Mr Williams stopped short of making a ruling to enforce changes after being left 'satisfied' that issues raised in the serious case review had been fully addressed.

The 12-day inquest heard how a breakdown in Dana's relationship with her foster carers left her devastated and at a heightened risk of suicide.

She moved in with an adult friend called Sally King, but took her own life two days later on March 1 in 2011.

Mrs King told the hearing she was given no advice or guidance on how to look after the schoolgirl.

The case review, chaired by the Worcestershire Safeguarding Children Board, said Dana could have been better handled following the split from her foster carers.

The board said it would develop a strategy to reduce incidents of suicide by ensuring professionals were aware of behavioural triggers.

Speaking after the conclusion of the inquest, Worcestershire County Council said it had invested £3.5m in children's social care and restructured the service to ensure social workers spent more time with families.

The investment resulted in the creation of 30 additional social worker posts last year, taking the number of workers employed by the county council to about 200.

The county council's cabinet member for children, Councillor Liz Eyre, said: "There is no doubt, that Dana always had social care and other professionals around her who cared for her.

"At the time of her death there were a significant number of professionals involved with her care.

"However, we see that we are the lead, co-ordinating agency with corporate parenting responsibility. Where we could have done better, we have made changes at the earliest opportunity."

Other improvements carried out by the council include working closer with schools, updating the risk assessment process and a more effective matching of young people with foster parents.

Councillor Eyre added: "All agencies, including ourselves, health services and the police have and are improving how we work together."

Gail Quinton, director of children's services at the council, said: "We have acted swiftly on areas identified for improvement and all actions in the serious case review have been undertaken.

"We have increased the number of social workers so that we have sufficient staff with the right skills and experience."

Diana Fulbrook, independent chair of Worcestershire Safeguarding Children Board said a single dedicated telephone line had been set up to create easier access to the Child and Adolescent Mental Health Service.

She said a Suicide Prevention Guidance document had been written for agencies and a management procedures was now in place which 'encouraged a more co-ordinated response and appropriate information sharing".

Mrs Fulbrook said: "Her tragic death happened over three years ago, we have been taking action all that time. We are in a very different place than we were three years ago and I hope that reassures the public."

Sporty 16-year-old Dana, who represented Great Britain in karate, was being fostered after it was revealed she was having a relationship with her martial arts teacher Jaspal Riat, then 49, who was later jailed for eight years for sexual abuse.

In coming to his judgement, coroner Mr Williams said Dana's human rights had been breached.

He said from March 2011, Dana was at a 'real and immediate risk of death by suicide', and this was known by those who cared for her.

He said: "I find that it would have been the simplest measures, and well within the power of the local authority, to have asked Sally King not to let Dana out of her sight and to arrange for visits on a daily basis by professionals."

He added: "In my judgement these simple steps would have avoided Dana's death on March 3 and therefore I consider that Dana's article two rights were breached."

In conclusion, he said Dana, who killed herself with a dog lead purchased from a pet shop, hanged herself with 'clear and deliberate intention of ending her own life'.

He added: "Her death was contributed to by a failure to have in place adequate measures to protect her from a known, present and continuing risk that she would kill herself.

"I find that Dana was extremely vulnerable, the nature of risk was completed act of suicide; the magnitude of the risk was very great indeed and that the protective measures were almost non-existent."