A series of failings and miscommunication were highlighted today as Sheriff Ruth Anderson, QC, gave her judgment following a 65-day Fatal Accident Inquiry into the deaths of Niamh Lafferty, 15, from Helensburgh, and Georgia Rowe, 14, of Hull.
The girls died after jumping from the bridge into the River Clyde on October 4, 2009. They had walked out their secure unit that night at 9pm.
They were both residents at the Good Shepherd Centre in Bishopton, Renfrewshire.
In her ruling, Sheriff Anderson was critical of the level of staff on the night they died.
She also said that proper regard should have been given to the serious nature of bullying to Georgia Rowe.
The sheriff said the girls' deaths may have been avoided if at least four staff been on duty and had the girls' accommodation been on the first floor of the Open Unit instead of the self-contained flat on the ground floor directly opposite a fire exit door that had no alarm.
Only two staff were on duty when the girls left.
The ruling also found their deaths were suicides.
Sheriff Anderson added: "There was a need for a more robust approach to the issue of absconding linked to the security of the premises.
"Management should have given proper regard to the serious nature of the bullying of Georgia Rowe by AM, a young person resident in the establishment at the time, and its impact on Georgia.
"Management should have taken appropriate steps to ensure the removal of Georgia or AM from her placement."
Communication errors were also highlighted.
Sheriff Anderson said these included: "The failure of placing authorities to hold detailed, comprehensive, concise and readily accessible information relating to an individual child to include the recommendations of the child's social worker/key worker and any psychological assessment, and to ensure this information was copied to the residential establishment on any placement of the child."
It was also deemed there was a need for a 'stand alone' risk assessment in documentary form for each young person in the care of a residential institution with separate consideration given to the issues of 'self-harm' and 'suicide.'
Sheriff Anderson said: "No 'stand alone' risk assessment was ever done on Niamh or Georgia by their placing authorities, nor by any of the residential establishments in which they were placed.
"Had such an assessment been carried out, regularly updated, and accompanied each girl to the various establishments in which she was placed, then management and staff charged with their health and safety would have had a readily accessible and comprehensive document as a valuable tool to assist them in their responsibilities and to alert them to the risks that pertained, whether those were in relation to absconding, self-harm or suicide."
During the inquiry, Stephen Platt, professor of health policy research at the University of Edinburgh, had made various recommendations, including judgement as to the risk of suicide. Sheriff Anderson said care authorities should follow his proposals.