By Anna Edwards PUBLISHED: 14:38 EST, 1 March 2013 | UPDATED: 14:42 EST, 1 March 2013 A Serious Case Review following the death of a teenager who was tied to a tree, tortured, sexually assaulted and killed has recommended 111 separate changes in procedure to the agencies that dealt with her. It found the extent of her vulnerabilities 'was not understood by professionals working with her' and a found a wealth of ways agencies care of her was 'weak'. Hannah Windsor, 17, suffered an horrific death last May at the hands of her sadistic boyfriend Adam Lewis, who pleaded guilty to murder, two charges of assault, burglary, and arson at his trial last year and denied two charges of rape.
@highlight
Hannah Windsor was tied to a tree, tortured and killed by her boyfriend
@highlight
Serious Case Review found that care was 'weak' for teenager
@highlight
No child protection plan was formulated for vulnerable 17-year-old
@highlight
No assessment took account of her developmental progress and information contained in key records was not adequately appraised
@highlight
Recourse was made to family members, friends and specialist housing provision - but there was no accurate evaluation to ensure that safe care was being provided for her.
@highlight
Warning signs of tension in the systems that surrounded Hannah were not always heeded
@highlight
Not recognising the extent of her vulnerabilities had a number of consequences 'which were significant.'
@highlight
Hannah's relationships and behaviours were not always understood in the context of both her learning difficulties and of the adversity she had suffered in life.
@highlight
The review found Hannah 'was not adequately diverted from harmful activities.'
@highlight
The local authority 'did not adequately consider its responsibilities under the Children Act to provide accommodation to her.'
@highlight
If Hannah had been accommodated properly, a core assessment could have been completed and more thorough understanding of what needed to happen next could have been developed.
@highlight
Promotion of her welfare was 'generally weak'
@highlight
No child protection plan was ever properly formulated.
The report describes how @placeholder was helping police find him but had been warned about approaching the killer by a policewoman.