Sam and Chris Gould: Twins case failures flabbergast ex-commissioner

Sam Gould (left) died in September 2018 and her twin sister Chris died a few months later

The former children's commissioner has said she was "flabbergasted" by some of the failures in the case of twin sisters who took their own lives.

Sam and Chris Gould, from Fulbourn, Cambridgeshire, died by suicide four months apart, aged 16 and 17.

Serious case reviews found a "fragmented" response by agencies after the girls reported sexual abuse.

Ex-commissioner for England, Anne Longfield, said she had a sense of "dismay" young lives have been lost.

Sam died at home in September 2018, while Chris died in January 2019 while she was an informal patient at a mental health unit.

Chris and Sam's parents Jane Cannon and Ian Gould are now fighting for change following their daughters' deaths

Hampshire Police investigated in 2016 after Chris disclosed she and Sam had been sexually abused from a young age, but at the time the girls were struggling with their mental health and did not wish to give video evidence.

The case was then closed, but the reviews said it appeared police guidance had not been followed and "alternative ways of giving evidence should have been explored".

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The reviews also found "ineffective" communication between agencies and a "missed opportunity" to understand "Sam's internal world", when she was pulling out her hair and eyelashes at a young age and had displayed sexually inappropriate behaviour.

Sam and Chris were each other's best supporter, their parents said

Asked about why it appeared no-one asked why the girls were displaying that behaviour and self-harming, Ms Longfield told BBC Look East: "What I think we're still in the situation of is that different parts of the system just see part of what's going on, they aren't talking about what's going on.

"But where you have some mechanism in place, a panel or the like, that can meet regularly, work out which children are looking like they need extra help and then working together to make sure they get it, then you get the best solutions.

"I'm flabbergasted that anyone thought that that was something that didn't need follow up and I think we've seen the tragic consequences of that in what we're reading in the serious case reviews."

All of the agencies involved have said they have since made changes following Sam and Chris's deaths.

Ms Longfield said the chair of the ongoing independent review of children's social care "recently called the care system a tower of Jenga held together by Sellotape".

"I think we need to look at how we enable those professionals who do want the best for those children to be able to come together and help those children from the start," she added.