A SERIOUS Case Review following the murder of troubled Wirral teenager Hannah Windsor has found the extent of her vulnerability "was not understood by professionals working with her.”

Seventeen-year-old Hannah suffered a horrific death last May after being tied to a tree and brutally tortured by her boyfriend.

Her attacker, Adam Lewis, also seriously sexually assaulted her during her ordeal at Bidston Hill. He then buried her remains in a shallow grave and fled.

At his trial in November last year, Lewis pleaded guilty to murder, two charges of assault, burglary, and arson. He denied two charges of rape.

The trial judge ordered he must serve a minimum of 22 years in jail.

Mr Justice Holroyde told Lewis “This was a prolonged, merciless and terrible attack which must have been agonisingly painful for Hannah Windsor before she died."

The case review was ordered immediately following the hearing.

The 83-page report, which is anonymised - referring to Hannah as "Child G" - contains 111 separate recommendations for changes to procedures, training and issuing extra guidance to staff.

It found that although her murder at the hands of Lewis could not reasonably have been foreseen, service provision by the professional agencies that were supposed to look after her was “diffuse and lacked co-ordination”

In the days before Hannah's death, Lewis had been sleeping rough hiding out on Bidston Hill after a warrant was issued for his arrest for burglary and arson.

The report describes how Hannah was helping police find him but had been warned about approaching the killer by a policewoman. However she ignored the advice.

CCTV pictures released after the trial showed the teenager walking along a leafy pathway at the hill as she went to meet him. She was dead a matter of hours later.

The review charts how Hannah had a difficult childhood and discloses that over the years, the youngster had contact with a large number of agencies and organisations.

Representatives of health, education, social care, police, youth offending and housing services were all involved.

Surprisingly, no multi‐agency “holistic” assessment of her needs, characteristics and behaviour ever took place.

No assessment took account of her developmental progress and the relationship she had with her family or their capacity to care for her.

Information contained in key records was not adequately appraised.

Recourse was made to family members, friends and specialist housing provision - but there was no accurate evaluation to ensure that safe care was being provided for her.

Warning signs of tension in the care systems that surrounded Hannah were not always heeded.

Not recognising the extent of her vulnerabilities had a number of consequences “which were significant.”

Hannah’s relationships and behaviours were not always understood in the context of both her learning difficulties and of the adversity she had suffered in life.

The review found Hannah "was not adequately diverted from harmful activities."

The local authority "did not adequately consider its responsibilities under the Children Act to provide accommodation to her."

If Hannah had been properly housed, a core assessment could have been completed and more thorough understanding of what needed to happen next could have been developed.

In February 2012, she was provided with accommodation, as a homeless young person.

An assessment should have taken place at this point to consider whether she was “in need” and required local authority accommodation.

Promotion of her welfare was “generally weak” and there was insufficient expectation of excellence in practice. The review says this relates more to professional attitudes than to process and procedures.

There was an absence at significant times of professional and managerial scrutiny and challenge.

For example, although Hannah was found to have been neglected, there was almost no challenge made to those responsible about the care they provided for her.

No child protection plan was ever properly formulated.

The report stresses that such a plan is the basic requirement of child protection work and each member of the core group had individual, as well as collective, responsibility to Hannah to ensure this requirement was met.

"However, to have done this, professionals would have needed expectation that change could be achieved through their efforts, resolution and persistence to see it through.

"Regrettably, core group members appear to have moved towards acceptance of this situation and their level of challenge diminished as time went on."

Local Safeguarding Children's Board procedures and good practice guides were not consulted and were not always applied as they were intended to be.

The review says: "This is not a new finding for the board. It is evident that LSCB procedures are comprehensive and easy to access.

"They provide helpful aids to assessment and judgement when working with children and families in different circumstances.

"Not referring to procedures, contributed to practice that was less thorough and judgements that were less acute that they need have been."

Finally, there may be practitioners and managers who, for reasons of their own, chose not to refer to procedures.

"This suggests non‐compliance with procedures is multi‐faceted and that no single solution is going to be successful in bringing about change in this area."

A press release from Wirral Council states: “The review found that agencies working with Child G could not have foreseen what happened to her.”

It continues: “The overview report makes recommendations, all of which are now part of an action plan which will be reviewed and updated regularly by the Local Safeguarding Children’s Board.

Dennis Charlton, independent chairman of the board, said: "I would like, on behalf of all members of the LSCB,  to extend our deepest condolences to Child G’s family and anyone who knew her.

"I know that a number of people who work for agencies associated with Child G’s care knew her personally, and were greatly affected and saddened by her death.

"The board have accepted the findings and recommendations of the Review which was commissioned by the LSCB following Child G’s death.

"We are already working on a number of areas which have been identified, where assessments, multi-agency work and information sharing were not of a sufficient standard to provide a framework for co-ordinated actions and interventions." 

Progress on these recommendations will be monitored and updated regularly by the LSCB, and the results will contribute to child protection practice in Wirral and will be used to inform further action and training.