A coroner has said she cannot be sure a 13-year-old girl who was found hanged after going missing from home intended to die.
Amber Peat was found dead three days after walking out of her home in Nottinghamshire in May 2015 following an argument about chores.
Assistant Nottinghamshire coroner Laurinda Bower considered whether to return a conclusion of suicide.
However, she instead returned a narrative conclusion.
“Considering Amber’s age, her emotional immaturity and her undoubted vulnerability, and the absence of any professional ever having properly assessed Amber’s risk of self-harm or suicide, I am not able to determine, on the balance of probabilities, Amber’s intention at the time of her death,” she said.
In her narrative conclusion, the coroner said there were no less than 11 missed opportunities for education, health and social care agencies to assess Amber and her family, and this may have prevented Amber’s death.
“Had those agencies responded to safeguarding concerns in an appropriate manner it is possible Amber would not have died when she did,” the coroner said.
The inquest has heard evidence from several of Amber’s teachers who had concerns about her life at home.
Amber told one teacher how her stepfather, Daniel Peat, had punished her by making her wear baggy grey jogging bottoms to school and carry her belongings in a plastic bag.
Mr Peat and Amber’s mother, Kelly Peat, accepted Amber had gone to school wearing the jogging bottoms and carrying a plastic bag, but said she must have lied when she blamed her stepfather for it.
However, the coroner found that Amber had been telling the truth.
“I find as a fact that Amber was made to wear the jogging bottoms to school and to use a carrier bag as punishment by Mr Peat in the full knowledge that she would be humiliated,” the coroner said.
“This was perhaps borne out of the frustration that he was feeling towards Amber rejecting his attempts to discipline her.”
‘Lack of emotional warmth’
The inquest heard evidence from a police officer who said Mrs Peat was “not particularly emotional, as in upset”, when her daughter went missing.
The coroner also noted a lack of emotion from Mr and Mrs Peat when they gave evidence at the inquest.
“On more than one occasion, professionals told me how they had witnessed Mr and Mrs Peat demonstrate a lack of emotional warmth towards Amber at times when one would expect emotion to be present, such as Amber returning home after being missing,” the coroner said.
“Indeed, when they gave evidence to this inquest there was a distinct lack of emotional warmth towards Amber, more so from Mr Peat than Mrs Peat.”
A statement on behalf of Mrs Peat was read out by a lawyer following the inquest.
“Like all parents, Kelly knows she is not perfect but she has done, and continues to be, the best parent she can for her children,” the statement said.
“Kelly wonders whether things could have been different had Amber and her family received more support and advice for Amber’s behaviour.
“She proactively sought help on numerous occasions with Amber, and tried to work with the agencies as much as possible.”
The statement said Mrs Peat had been “subjected to intense media and public scrutiny” since Amber’s death.
“Some of the things that have been said have been very hurtful not only to Kelly, but her family too, and they have had a huge impact on their well-being,” the statement said.
The statement said Mrs Peat “will always wonder” why Amber did what she did.
“She and her family find it impossible to believe that Amber purposely set out to take her own life,” the statement said.
“Kelly feels strongly that Amber would not have meant to deliberately harm herself or mean for this to happen.”