SERIOUS shortcomings have been identified by a major independent inquiry into the circumstances leading to the death of murdered Inverkip teenager Margaret Fleming.

A Significant Case Review (SCR) was commissioned to examine the role of all the agencies that were involved with vulnerable 19-year-old Margaret during her life.

It was led by Professor Jean MacLellan OBE, who spoke to more than 100 people, including the teenager's family and friends, during her 'wide-ranging review'.

The report highlights a series of lessons to be learned by the authorities.

It reveals that breakdowns in communication played a key role in how evil killers Eddie Cairney, who died in prison at the weekend, and accomplice Avril Jones were able to murder Margaret at their filthy Seacroft cottage and get away with it for a staggering 16 years while claiming benefits worth over £180,000 meant for her.

READ MORE: Margaret Fleming murder: Killer Eddie Cairney dead

A series of recommendations have been made for all the agencies involved to implement.

The handling of Margaret's case by benefits bosses, social workers, the police and GPs is put under the microscope in the report.

In a damning indictment, it says that Margaret 'was invisible at the time of her death'.

The report added: 'She was gradually and systematically removed from her world little by little and step by step.

'EC [Eddie Cairney] and AJ [Avril Jones] exploited Margaret, the primary motivation being financial gain.'

The review highlights how the Department for Work & Pensions and others could have intervened at a crucial point in her life, when Cairney and Jones were allowed to step in and look after her following the death of her father.

It said: 'When EC and AJ assumed ‘carer’ status, this went unchallenged.

'In the case of the Department for Work and Pensions, AJ’s status was accepted within their policy and procedures at that time.'

The report adds: 'In the case of one of the GPs, their status was accepted positively in that when he saw Margaret when she lived with them she was slim, having had weight management issues throughout her life.'

Away from professionals and the authorities, the report also found that individuals in the community also missed key chances to raise the alarm about what was happening to Margaret.

It says: 'Margaret was observed by individuals who visited Seacroft with tubing on her arms, duct tape on a wrist and calling in distress from a bedroom window.'

But tragically the serious case review notes that 'the individuals concerned failed to report the harm'.

The DWP's continued benefit payments over more than a decade and a half are pinpointed in the report as a baffling failure.

It says: 'The Department for Work and Pensions continued to provide benefits for over a sixteen year period without seeing Margaret.

'In doing so, they largely followed their stated policies and procedures.

'This stark fact is difficult to comprehend and accept.

'They accepted that Margaret was too scared to see them on several occasions.'

Health services are also facing questions following the probe.

The report remarks that 'Margaret almost gets lost in health services overall'.

It adds: 'No health professional ever raised any child protection concerns and no other agency contacted health to raise any concerns or to get any further information'.

Social work involvement is also scrutinised.

The report details how in February 1997 Margaret’s mother asked for her case to be reopened as 'her daughter’s behaviour had deteriorated'.

It goes on: 'No assessment or allocation appears to have taken place.'

The final social work referral prior to Margaret’s death was made in October 1998 by her mother, who alleged that she had been assaulted by Cairney in November 1997 when 'she had gone to see her daughter and was no longer allowed to see her'.

She was concerned for her daughter’s welfare and the workers involved referred the matter to the Female & Child Unit at Greenock Police Station, as they were already dealing with allegations that Margaret’s paternal grandfather was being exploited by Cairney.

But the report says: 'Some limited efforts were made by Social Work to follow up the referral and the case was closed'.

The inquiry author says that Margaret’s situation could have been referred to the Children’s Reporter for consideration at this point, something which could potentially have led to her being placed under supervision and tragedy being avoided.

Adult social work services are another key focus of the report.

It finds that the DWP made a referral to them in June 2012, having paid a home visit to Seacroft.

They were concerned about the state of the house and that they were unable to see Margaret.

Social workers said that this referral 'did not explicitly flag up an adult protection or an adult welfare concern'.

The report says a social work manager 'closed the referral in September having taken no action on the basis that Margaret‘s permission to refer had not been obtained'.

Another key finding concerns the police and their involvement, after Margaret’s mother’s allegation of being assaulted by Cairney and not being allowed to see her daughter.

The report said: 'When they investigated Margaret was viewed as a potential witness and dismissed as being ‘obviously mentally handicapped' and that she was ‘perfectly happy living at Seacroft’.'

It adds: 'Margaret’s needs and safety were not considered when they should have been'.