Nadia Shah's case reveals an 'absence' of council and NHS services working together, says a review.
said numerous referrals were made by NHS teams to Cambridgeshire County Council's children's services, but they were "open and shut".
Last year, Elysium Healthcare, which runs the clinic, apologised for the "shortcomings in care" after an inquest jury found multiple failures, including issues around observations and Nadia's care plan.
"Numerous referrals were made to children's services in an attempt to elicit their involvement but, as put by a panel member, the response by children's services to Nadia and her family was to open and shut, open and shut. The Potters Bar Clinic, where Nadia was detained at the time of her death, is run by Elysium Healthcare
A county council spokeswoman said the authority fully supported the review's findings, adding: "Significant changes have already been made with partners from the police, the NHS, schools and community groups, to enable us to work together more effectively.
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