The case of a mother who died with her son after jumping from Haytor last July "could not have been avoided", according to a Serious Case Review.
The review has been published into the deaths of the Devon mother and her two children who died in the county last year.
Katherine Hooper killed herself and her five year old son Joshua when she jumped from Haytor with him of her shoulders in July 2013.
A few miles away at the family home in Paignton, Kat's two-year-old son, Samuel, was found lying dead on a bed.
Today a report into the handling of the case by Torbay Social Services has been published. It's concluded that the deaths "could not have been avoided" but has highlighted areas from improvement. These include closer working between different agencies and making sure that effective supervision is available for staff involved in Safeguarding work.
The report states: "There was a tendency for professionals to work in 'silos'; i.e. to view aspects of need narrowly, solely from the perspective of their own discipline.
"Most of the services had some knowledge of some indicators of potential risk and vulnerability but this was not brought together into a holistic assessment."
This case review concerns the services provided by the police, children's services, mental health services and domestic abuse support services provided to Kat Hooper and her children following a domestic incident in April 2013 where she took an overdose in an apparent suicide attempt, the father was charged with assault and the children were taken into foster care.
It concludes family, friends and the professionals involved with the Kat did not think that suicide, let alone the death of her children, was likely and that no in-depth analysis was carried out on her parenting ability after the attempted overdose. It says the potential risks to the children were overlooked as the focus centred on reuniting the children to the care of their mother.
In response to the report, a Torbay Council spokesman said: "The conclusion of the review found that these deaths could not have been avoided. However, the review has highlighted a number of findings and as a result has recommended the following actions."
The actions are: - All partner agencies demonstrate that effective supervision is available for all staff involved in Safeguarding work.
- There is a shared approach to assessing and understanding risk.
- Closer working between all agencies through joint training, in particular adult mental health.
-There is an agreed process for investigating historic abuse allegations.
- There is a review of preventative mental health services.
The Independent Chair of Torbay Safeguarding Children's Board, David Taylor, added: "This was a very tragic event and I would like to reassure everyone that the Safeguarding Board and all its partners take the recommendations in this review extremely seriously.
"As the review states these deaths could not have been avoided, but we can always improve on what we do. As such, the Board will continue to review and raise the quality of practice in Torbay to ensure partner agencies continue to improve their integrated working.
"The Board and I are committed to keeping children, young people and their families safe and through close consideration of such cases like this we continue to build on the improvements we have already made to offer the best protection possible."
An inquest earlier this year in Torquay found Kat took her own life, Joshua was unlawfully killed, while an open verdict was recorded into Samuel's death.
