A review into the care of siblings Amber and Connor Gibson has found professionals could not have predicted the teenager would murder his younger sister.
Amber was living in Crosshouse children's unit under the care of South Lanarkshire Council when she went missing on the night of November 26, 2021.
Her body was found days later in Cadzow Glen in the town following a high profile missing person's campaign.
The 16-year-old had been sexually assaulted and strangled by her older brother.
A second man, Stephen Corrigan, who was a stranger to the siblings, had initially found her body but, rather than contact police, he interfered with her body, intimately touching her, and then concealed her remains.
READ MORE: Family say Amber Gibson was let down by the local authorities
South Lanarkshire Child Protection Committee (SL CPC) ordered a Learning Review, which was carried out by an independent reviewer under the National Learning Review Guidance for Child Protection Committees.
Its findings have now been published and determine that, despite the complexities of the case and multiple agencies involved with the care of both teenagers, Amber's death could not have been foreseen.
Professor Soumen Sengupta, Director of Health and Social Care, said: “Our thoughts remain with everyone who loved and cared for Amber, and who continue to mourn her.
“The circumstances of Amber’s death were truly terrible and are deeply distressing.
"As a young adult Amber was just at the start of the next chapter of her life when she was so brutally robbed of her future.
"It is of very little consolation that the guilty parties are now in prison paying for their horrific crimes.
"We welcome the conclusion of the independent Learning Review and note its key finding that Amber’s murder could not have been predicted by our staff or any of the professionals who were involved in the care of her or her brother."
The young people were received into care in 2008 at the ages of three and five and, following a long history of child protection concerns, South Lanarkshire Council secured a permanence order for both children in 2014.
Their Compulsory Supervision Orders were terminated at that point and parental rights and responsibilities were withdrawn from their birth parents.
Amber and Gibson lived with foster carers Craig and Carol Niven before Amber moved to Crosshouse and Gibson moved to homeless accommodation.
The Learning Review details how both young people's mental health and psychological functioning were assessed to have been seriously impacted by their experience of extreme trauma from birth until they were removed from the care of their birth parents.
As well as being provided with, the report says, "a nurturing home environment" with the Nivens, there was sustained support by social work, CAMHS (Child and Adolescent Mental Health Services), education services, intensive family support and other services.
The report highlighted there was no recognised framework to bring agencies together to assess and manage young people who may be displaying harmful sexual behaviour and recommends this should be put in place.
A criticism in the report details a delay in securing permanence for the brother and sister.
It was two years from Amber and Gibson moving to their foster placement before permanence planning began and a further four years after this decision for the permanence order to be secured.
READ MORE: Connor Gibson found guilty of the murder of his sister Amber
The report states: "For both young people, the delay in securing their future caused distress and uncertainty which impacted their emotional wellbeing and behaviours."
It adds that a decision was taken in 2011 that both young people should not be placed together and that an alternative singleton placement be found for Gibson.
However, there was no evidence that an alternative placement was sought and they continued to live in the same care placement.
The report adds: "Inspection reports have significantly improved their permanence planning processes, and while drift and delay can still be a feature, it is not the norm.
"Local Government Benchmarking Framework (LGBF) and local authority looked after children’s data (CLAS) returns indicate that South Lanarkshire is now one of the better performing areas for permanency planning."
The review also deals with the issue of sexually inappropriate behaviour by Gibson, which his trial heard had been reported to agencies by Mr and Mrs Niven.
It said there was no evidence of multi-agency risk management meetings being convened or any agreed frameworks to guide staff in the assessment and management of concerning behaviours.
Prior to his sister's murder he had never been charged with a sexual offence and so was not being managed through the children's hearings system or youth justice.
The report says: "There were incidents over the years which could have led to charges being brought which would have given a legal mandate for worker’s interventions.
"This was discussed at length in both the practitioner and manager workshops with no definitive agreement as to what impact this would have had on both young people whose behaviours were often an indicator of their distress and trauma.
"The workshop highlighted workers did not feel confident in this area of practice reflecting the need for basic awareness at all levels across all partner agencies."
It was also highlighted that lengthy legal processes and delays can have a significant impact on child victims and witnesses, and the report repeats calls for reform of services.
The report adds: "It has been recognised for many years that the Scottish Justice system needs to reform to meet the needs of child victims and witnesses.
"This case only highlights the need for reform."
Gibson, whose actions were described in court as "truly evil" is now serving at least 22 years behind bars.
Corrigan, whose lawyer told the court he maintains his innocence, despite a jury finding him guilty of the crime, was jailed for nine years.
During Gibson's trial the media were prevented from reporting on the outcome of another case - the sentencing of Amber and Connor Gibson's biological father.
Peter Gibson was found to have sexually assaulted two young boys and assaulted and raped a woman between 2001 and 2008, and he was jailed in April last year.
Prof Sengupta added: "The review also noted that it was evident that all the professionals who worked with both young people did so with a focus on their health and wellbeing through often very challenging times.
"All the agencies involved are committed to responding to its recommendations.
"Wherever we can make improvements for the children and young people in our care we will strive to do that."
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