TROUBLED teenager Mary Stroman, who killed herself under a train at Yarnbrook, was failed by both the police and social services, who were supposed to be caring for her after she had suffered traumatic sexual abuse.

Mary died in January 2014, after leaving the Tumblewood Community School, a residential school for adolescent girls with emotional and behavioural difficulties in nearby Heywood, one night.

This week a Serious Case Review commissioned by the Haringey Local Safeguarding Children Board issued its report, which refers to Mary as Child O, calling Haringey Children's Services' response confused and inactive, and criticising the disarray it saw in the management of the case.

The police were criticised for doing nothing, although in 2012 they had been told that Mary, who lived in London with her family, had been a victim of a child sexual exploitation gang from the age of 12.

This week Mary's parents, Scott and Sue Stroman, said: "We wish to honour Mary’s life by making public the circumstances which led to her death, in the hope that lessons will be learned and other families spared the suffering we have endured.

"We welcome the findings of the Serious Case Review.

"Despite all the failures, we blame no-one personally. Indeed, we would like to thank the many, many dedicated professionals who attempted to help Mary, and the army of friends and colleagues who have supported us through the most traumatic period of our lives.

"A bright, witty and popular girl, Mary was much loved by her parents and four siblings. She was apparently successful in school, socially and with her many activities.

"But we now know, starting when she was around 12 years old, Mary was groomed and sexually abused by men in the area of north London where we live.

"She slowly declined in mental and physical health, evidently as a result of Post Traumatic Stress Disorder. Mary suffered more than four years of mental anguish, self-harm and illness, culminating in her tragic death.

"Our experience in trying to help our daughter was one of encountering earnest people lost in a sea of procedural confusion, bad communication and occasional disarray. The report clearly highlights these issues and we welcome its directness and honesty.

"Sir Paul Ennals, the chairman of the HLSCB, expresses sincere regret for the shortcomings of agencies in Haringey and we are grateful for that. However, similar failings have been identified in previous Serious Case Reviews in the borough.

"If someone like Mary needed help today, given that we now understand so much more about the risks such children face, we earnestly hope the response and the outcome would be different."

The report says that the involved agencies had not learned lessons from previous cases of abuse and deaths of children.

In October 2014, an inquest into Mary's death heard that the driver of the First Great Western service from Portsmouth to Bristol Temple Meads saw a figure on the line but was unable to stop in time.

A post-mortem examination found Mary had died instantaneously from multiple injuries.

Wiltshire and Swindon coroner David Ridley concluded Mary had taken her own life while suffering from complex post-traumatic stress disorder.

"Mary suffered severe mental trauma, more likely than not as a consequence of previous episodes of sexual abuse," he said.

"However, due to Mary's reluctance to disclose these details, details of exactly when and where these incidents occurred are unclear but I am satisfied she suffered mental trauma as a consequence.

"I make no finding that anyone ought to have known that Mary was going to take her own life. Tragically, I fear what happened was spontaneous."

The coroner said the notes Mary left behind in her room at Tumblewood referred to the "perpetrators of abuse".

Mary had left the home on Hawkeridge Road on the evening of January 14, 2014, only a short time before she killed herself at 8.20pm. At the time police said they had received reports of a missing person in the area before the tragedy on the rail line, which is only a short walk from the school.

After the inquest, Tumblewood released a statement, which expressed "sincere condolences" to Mary's family for her "tragic" death.

"Mary was a popular and bright member of the community with a good sense of humour," it said.

"She was an accomplished artist and musician and had an affinity with animals, especially horses. Mary is greatly missed by staff and children."

The report says that Haringey Council’s child protection services did not carry out a risk assessment which would have ensured Mary got the most appropriate treatment and that any threats to her wellbeing were dealt with, and that there were delays in giving her a private residential placement.

The report suggests concerns about the cost of the placement may have led to those delays.

It also criticised police, saying they when they were given a letter saying Mary had been sexually abused, they made no formal record and the letter was lost.

The report says that: “This review has identified very serious weaknesses across the services which should have helped Child O and her family, stemming from an overall failure to use safeguarding arrangements and risk assessments effectively.

“But there was also clearly a significant, avoidable delay in taking a key action – agreeing to her and her family’s request that she be admitted to the public care, to live separately from her family in a therapeutic placement - which probably had the best chance of achieving enduring, positive change.

"No consideration was given to undertaking a risk assessment of the known and perceived risk being posed to Child O.

“That risk assessment should have analysed and addressed the many threats to Child O’s well-being – sexual exploitation, her own mental ill-health, the extent to which her parents could keep her safe within and outside the home.

“Assessment should lead to planning, action and review. Instead there was repeatedly confusion and inactivity.”

It said the first assessment concluded in December 2011 saying that Mary should be seen as a "child in need.”

Just over a month later there was a decision that the case be closed, with no action taken.

The report said it was clear that Haringey Council’s unwillingness to pay for specialised and expensive care was a factor in the decision.

In January 2012, the report said, police received a further referral. This contained a letter written by Mary to a former fellow pupil, describing the abuse she had suffered.

But the officer in charge of the case had said he decided not to take any action, and the letter itself was not kept by police. The officer made no formal record of the content of this letter.

The report said of the letter that, whatever its veracity, should have led to immediate action under child protection arrangements.”

A Haringey Council spokesman said: “As the report makes clear, this was an exceptionally complex case and it is tragic that the many professionals – from a range of different fields – who worked with Child O and tried their best to support her were ultimately unable to prevent her very sad death.

“We accept the findings of the review and recognise that at times during this very complex case some mistakes were made, for which we apologise.

“We have fully implemented recommendations from this review, including quarterly independent reviews of care plans; strengthening the role of Independent Review Officers; making decisions in complex cases in a timely manner, and monthly case management audits to ensure compliance with robust procedural and good practice requirements.

“We also now have far greater stability across our children’s services, with permanent senior management leading a dedicated team of staff who are all committed to delivering further improvements and continued learning, supported by the council’s new senior leadership team.”

A statement from the Met Police said: “The MPS fully supports the findings of the Serious Case Review and takes on board the learning from this tragic case.

“Following a management review regarding this case, recommendations have been accepted by the Metropolitan Police, amounting to personal learning for the officers concerned and procedural changes.

“There is no internal investigation.”

Cllr Liz Morris, Haringey Liberal Democrats children’s spokesperson and deputy leader of the opposition, said: “Labour-run Haringey Council can only win back public confidence in its children's services if it implements the recommendations from the review and actually improves the services it provides to vulnerable children and families.

“Child O was suffering from a serious mental illness; she regularly and severely harmed herself making several violent attempts on her life.

“Worryingly, funding concerns may have been prioritised by the Labour council over the immediate needs of this extremely vulnerable child.

“I also urge the police to ensure that officers involved in cases like this always contribute to future reviews.”

Jane Hicks, chief executive of Tumblewood Community School, said in a statement today: "We would like to offer our sincere condolences to the family. Mary attended Tumblewood Therapeutic Community where she received therapeutic services, residential care and education.

"The directors have been working closely with all agencies in order to facilitate the Serious Case Review and the subsequent report".