Watch a video report by ITV News Anglia's Hannah Pettifer
The parents of teenage twins who took their own lives following years of sexual abuse and mental health problems believe opportunities were missed that could have saved them.
Sam and Chris Gould died within months of each other after struggling to cope with the consequences of the abuse that they had kept a secret for nearly a decade.
As serious case reviews are published looking at the care and support they received, their parents told ITV News Anglia that, despite the girls' repeated suicide attempts, "there was never a point that anyone gave up hope".
The two reports, published by Cambridgeshire and Peterborough Safeguarding Children Partnership Board, have come up with around 20 recommendations for improvements across the two cases.
They include changes in the way police approach sexual abuse victims, the education provision for children with mental health issues, as well as procedures for mental health services, children's services, and how all of those agencies work together on complex cases.
Despite that, the serious case reviews do "not conclude that, had these things been in place" either of the sisters "would be with us today".
But Sam and Chris' parents, Ian Gould and Jane Cannon, said they believed there had been multiple chances to save their daughters that were missed by the professionals dealing with them.
"If the issues that they had had been spotted earlier, treated earlier, if the professionals at an earlier stage had been more curious, we think there were many opportunities early on to help them," said Ms Cannon.
"Opportunities to stop the abuse happening at a much earlier stage and give them the care and therapy they needed. Clearly, the longer it went on the worse it got for the girls and for us and the harder it would have been to make a difference.
"But there was never a point that anyone gave up. There were many opportunities that we believe that, had things happened differently, we would be in a completely different place."
What happened to Sam and Chris Gould?
The sexual abuse of the twins began when they were about six years old, and living in Hampshire, and continued for several years. Their teachers saw worrying behaviour early on, including Sam pulling out her hair and eyelashes.
But it was not until Sam began self-harming at the age of 13 that any support was offered, by which time the family had moved to Cambridgeshire. Chris took an overdose for the first time at the age of 14 and, while in hospital, admitted she too had been self-harming.
Weeks later, she finally told a friend about the sexual abuse she had suffered. Sam revealed she had also been abused during the police investigation.
But because neither twin felt able to do a video interview, police closed the case just months later. On hearing no action would be taken against their abuser, the twins' parents told the report authors: “The girls felt completely invalidated”.
Sam died on September 2, 2018, having taken her own life, aged 16. Chris died less than five months later, on January 26, 2019, at the age of 17.
Inquests held earlier this year concluded Sam died as a result of borderline personality disorder (BPD) related to her childhood sexual abuse, while Chris's death was due to BPD linked to the abuse, and the loss of her sister.
Coroner Nicholas Moss raised serious concerns about how the two girls were treated, which he highlighted in a Prevention of Future Deaths report.
What do Sam and Chris's parents say?
Ian Gould and Jane Cannon believe one of the biggest failures in their daughters' cases was a failure to diagnose their Borderline Personality Disorder early enough and offer appropriate treatment.
They say mental health professionals remain reluctant to diagnose personality disorders in young people, meaning children and adolescent mental health services (CAMHS) do not tend to have provision in place to treat them.
But throughout their struggles, Sam and Chris repeatedly told their parents and therapists that they needed a way to understand what was happening to them.
When Sam was first diagnosed with BPD, she described it as "like a road map of me".
Ms Cannon said: "We would have wanted mental health services to follow NICE guidelines, to identify young people with emerging personality disorders. Spot it early, treat it early. Some people don't want diagnoses. Our daughters did."
Mr Gould added: "We still have the situation where CAMHS don't have the treatment for people showing borderline personality disorder. When they see people moving along that trajectory, they don't have any tools to deal with it."
Why did police not investigate the abuse?
Hampshire Police, the family's local force at the time of the alleged abuse, said it was "reflecting on these findings" and would be working to improve its service to victims of serious sexual abuse.
"We will review the recommendation made about working with other agencies, particularly where complainants live in another force area, and consider whether there are any further measures we can take," said a spokesman.
During the investigation in 2016, officers "engaged directly with the family and our approach to this case took into account their views, as well as the strength and availability of evidence", he added.
"Our assessment was that there was insufficient evidence in this case to provide any realistic prospect of conviction, and the decision to take no further action took account of the wishes of the victims and the wider concerns of the family at the time.
"Following the girls’ tragic deaths, we carried out an internal review of the investigation, and changes to some internal processes regarding how these cases are graded and allocated have already been made."
The force said it had a "child-centred policing strategy" which aimed to put "the protection of young people and children at the heart of everything we do".
What have the authorities said?
None of the named authorities were able to make anyone available for interview over the report, but all responded with statements in which they said their thoughts were with Sam and Chris's family and friends.
A statement for Cambridgeshire and Peterborough NHS Foundation Trust said: "We welcome the findings of the serious case reviews published today, and we will continue the improvements already made to our services, working with partners to ensure all learnings from the reviews are acted upon."
The trust has since set up a crisis team for child and adolescent mental health services to provide expert assessments and has established a new home treatment team working with young people so that they can remain at home, where appropriate. It is also currently developing a service for young people with severe eating disorders.
The trust also holds regular meetings with its partner to discuss children and young people with complex mental health needs to coordinate multiagency plans.
A spokesman for the Cambridgeshire and Peterborough Clinical Commissioning Group added: “We are working closely with partners to review the findings of this report and the Serious Case Reviews and we are committed to making further improvements on the basis of the recommendations, building on the changes that we have already implemented.”
Cambridgeshire Police said: "Along with our safeguarding partners, we have strengthened our approach and responses to the investigation of childhood sexual abuse.
"We adopt a holistic approach, which recognises strength in jointly working with our partner agency colleagues throughout the course of an investigation, and signposting to support services. We are committed to embedding the learning from these serious case reviews."
The mental health campaigner and founder of the charity SANE, Marjoirie Wallace described the sisters' deaths as "profoundly tragic".
She said: "We hear this time and again that the parents feel things could have been done and they were not listened to at the time.
"That's partly to do with the culture of not listening to the families early enough and it's partly the resources because the child and adult mental health service teams are overstretched and under-resourced."
If you have been affected by the issues raised in this article, you can find help and support on the ITV Mental Health Advice site.