A teenager died sniffing aerosols minutes after leaving a care home responsible for her safety, an inquest heard.
Darlene Bell, 15, was found in a playground in Newtownards, Co Down, late at night last June after telling staff at the unit that she was going out to get cigarettes.
She had used solvents in the past and was at the Ashgrove Centre care home in Newtownards, having recently been moved from a secure home which she could not have left at will.
Coroner Joanne Donnelly quizzed social worker witnesses at the Belfast inquest about why the disturbed adolescent, who suffered a litany of abuse in her early years, was able to leave.
Ashgrove night supervisor Gordon Moore said: "Ashgrove is not a secure centre, the locked gates are to keep people out, they are not to keep people in."
Darlene and her friend stole two aerosols from a nearby garage and went to the playground to inhale the gas using bags.
In a statement to the Belfast inquest, Darlene's teenage friend described how she came out of her "high" to find the victim with her eyes rolled back and foam coming from her mouth. She called an ambulance and commenced CPR, but Darlene was later pronounced dead.
A pathology report said her heart rhythm would have been disrupted by the butane gas produced by the aerosol. Senior social care worker Maeve Duffin said: "Darlene had abused solvents in the past (but) that was not a current risk... there was nothing to suggest that was going to happen."
Darlene had been in Ashgrove from the July prior to her death, but there were four incidents of suspected solvent abuse between then and her final abuse.
Darlene had a history of absconding from Ashgrove. That winter she was also abducted from the unit and brought to Burnley, England, by a relative to meet her father Aaron Bell. She was returned to Northern Ireland by police and placed in the Lakewood secure centre. It was shortly after her transfer back to Ashgrove on May 26 that she died.