CONCERNS for the welfare of teenager Jess Blake were not passed on to health and social workers by Humberside Fire and Rescue Service.
Jess, 14, was found hanged in woods on the outskirts of Beverley after going missing from her home in August.
She had a history of self- harm, cutting her forearms and neck with a razor blade, and was involved with mental health services until February this year.
In March, a fire officer raised concerns about Jess's safety after she started a fire in her bedroom.
Beverley station crew manager Shaun Harrison told how he realised "there was something wrong" when he was called to Jess's house on March 9 after she set her bedroom alight.
In a statement read out at the inquest into Jess's death on Friday, Mr Harrison said: "Jess was upset and crying. She also seemed to be a little in shock."
He noticed a mark on her wrist as he talked to Jess.
In his statement, he said: "It may have been from a bracelet or a watch, or it may have been something more sinister."
Mr Harrison filled out a CP1 form, an internal document used if firefighters come into contact with a child they feel could be vulnerable.
The form was given to Humber Fire and Rescue Service's safeguarding officer.
It could then have been shared with social services and health professionals.
But the document was never sent on and six months later, Jess was dead.
The Mail understands the person responsible no longer works as safeguarding officer but is still employed by the fire service.
Jess was visited by members of the service's fire- setting intervention team.
A spokeswoman said: "The form was acted upon.
"Fire-setting intervention was instigated by Humberside Fire and Rescue Service directly with Jessica."
But she acknowledged information in the form was not shared with other agencies.
East Riding Safeguarding Children Board is carrying out a Serious Case Review into the circumstances surrounding Jess's death.
Julie Abraham, East Riding Council portfolio holder for children and young people, welcomed the investigation.
She said: "I think it's the right decision that a Serious Case Review is going to take place.
"All agencies will be around the table, sharing their dealings with Jess and her family.
"Lessons will be looked at and an action plan, if there are issues arising, will follow.
"I welcome that very much and I think it's what the public will want to hear."
At the inquest into Jess's death, coroner Geoffrey Saul said her death may have been a cry for help gone wrong.
Recording a narrative verdict, he said: "She died from hanging at her own hand but the question of intent remains uncertain."
