DOCTORS and social workers have been criticised for a litany of failings after a disabled 12-year-old boy from Yorkshire died from swallowing one of his mother's prescription drugs.
Care professionals had been working closely with the boy and his family for seven years before his death, during which he was taken to hospital at least six times for swallowing or chewing harmful objects.
The boy had even taken his mother's medication before – when he was aged only five or six – and had only recovered from the near-fatal dose after undergoing treatment in intensive care.
His parents were arrested during a 14-month police investigation into his death but the case was dropped after prosecutors decided there was insufficient evidence to bring charges.
Details of the tragedy are revealed in the executive summary of a serious case review, which exposed a catalogue of flaws in authorities' dealings with the family.
The review panel made 11 recommendations for improvement after studying the roles played in the case by North Yorkshire's county council, police force and health trusts, as well as GPs, South Tees Hospital NHS Foundation Trust and the children's charity Barnardo's.
The boy, identified only as 'Child D', was the oldest of three children and experienced a range of health and behavioural problems caused by "a condition which affects physical and intellectual development in children".
Social workers began working with him in 1999 and have had continuous involvement with his family since early 2002. He died last year.
"Although Child D had very complex health needs, the death was completely unexpected," the report states. "Child D's father had found Child D face down on the bedroom floor in an awkward position one morning, and called an ambulance. Attempts at resuscitation were not successful, and very soon after admission to hospital, Child D's death was confirmed."
Toxicology tests later revealed he had ingested a "significant quantity" of a drug which had been prescribed to his mother, who had mental health problems.
Police arrested the parents three months after his death, following the report of a consultant paediatrician who thought it unlikely that the boy would have been able to administer the drug himself.
The boy's siblings were looked after by members of their extended family for more than a year while their parents remained under investigation but the criminal inquiry ended when a review by the Crown Prosecution Service found there was insufficient evidence to establish how the boy came to swallow the drug.
At an inquest earlier this year, a coroner recorded an open verdict after hearing that there was no evidence that either parent had harmed the child.
The review panel found the boy had been admitted to hospital accident and emergency departments at least six times between 2002 and 2007 for swallowing or chewing harmful objects, but health professionals failed to suspect an "emerging pattern".
The first incident, in which he ingested two of his mother's tablets, was so serious that he had to be treated in intensive care.
The tablets were a "potentially lethal dose for a child of that age", the report states, but there was no investigation into how the boy was able to access them. Care professionals were told he had found them while playing.
In an unrelated incident earlier that year, the boy had apparently suffered a minor injury after falling from a first-floor window, although there is no record of medical treatment having been sought.
The report stated: "Given that it has never been established how Child D came to ingest the prescription medication which was the cause of death, and that no-one has been identified as having been responsible for the death, it has not been possible to reach a conclusion about whether the outcome might have been different if different actions had been taken.
"However, detailed consideration of how agencies and professionals assessed and met needs in the period before Child D's death, and of the work undertaken to protect Child D's siblings after the death, has provided the opportunity to learn lessons and identify improvements which can be made."
The review was carried out by North Yorkshire Safeguarding Children's Board under the guidance of an independent child protection expert, Anne Hutson.
Its chairwoman Nancy Palmer said the board accepted all the panel's recommendations.
"It has produced an action plan based on those recommendations, many of which have already been implemented," she added. "We are satisfied that progress has been made against the remaining recommendations."