The care of a teenager who died from sniffing aerosols minutes after leaving a social welfare home responsible for her safety should be fully assessed by the health authorities, a coroner has said.
Darlene Bell, 15, was found in a playground in Newtownards, Co Down, 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 unit which she could not have left at will.
Coroner Joanne Donnelly delayed delivering her findings until she clarifies whether Darlene's care was properly reviewed by officials.
"It is not a summary of the care we need, it is an analysis and an assessment of the care to see whether there are any lessons that can be learned," she told the Belfast inquest.
A case management review was ruled out by the health authorities and there is uncertainty over whether an adverse incident report was drawn up. The coroner has received a seven-page summary of what happened in Darlene's case from the South Eastern Health and Social Care Trust.
A pathology report said her heart rhythm would have been disrupted by the butane gas produced by the aerosol.
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.
The coroner said: "I hope to clarify whether there has been a serious adverse incident review. Any such review may identify further information that is of relevance to the inquest.
"I would be very surprised indeed if there has not been or is not to be a proper, detailed review of the circumstances of Darlene's death by the trust or the appropriate body to see whether there are any lessons that can be learned."