A seven-year-old Hampshire boy died after the authorities failed for four years to take action despite 18 opportunities to step in, a Serious Case Review has found.
Blake Fowler suffered a severe head injury at his home in December 2011 from which he later died.
An inquest in November 2013 recorded an open determination and heard that a post mortem examination showed that Blake died as a result of a brain haemorrhage.
Following the inquest, Hampshire police reopened its investigation after a review was carried out of the original inquiry.
His mother, stepfather and step-uncle were arrested last year but the Crown Prosecution Service ruled that no further action would be taken against them due to lack of evidence.
Concerns for ill-treatment were first made in November 2007 and despite numerous contacts between Blake and the health and social care services, he remained with his family at their home in in Cromarty Road, Southampton, until his death more than four years later.
Keith Makin, independent chairman of the Southampton Local Safeguarding Children Board, said that the errors made were “simply unacceptable” and there had been “significant failures” in the child protection system in the city.
He said: “Blake was only seven years old when he died in 2011. His family were well known to local services in Southampton as a result of domestic abuse and there had been long-term concerns about Blake’s safety.
“The Serious Case Review highlighted several missed opportunities to help Blake and a number of significant failures in our child protection system. The errors made in this case were simply unacceptable.
“On behalf of the Southampton Local Safeguarding Children Board, along with colleagues from the council, police and health services in the city, I would like to say how sorry we are that Blake did not get the help that he needed.
“Our local safeguarding services in Southampton have significantly improved since Blake’s tragic death. Over the past two years we have been working to transform child protection services but we are not complacent. Progress has been made but our work is not yet finished, we are committed to doing everything possible to ensure that children in Southampton today are safe from abuse and harm.”
In one example, just before starting school in September 2008, Blake was referred to Children’s Social Care Services (CSC) by Southampton General Hospital after presenting with a bruised penis and facial injuries.
Despite the consultant paediatrician giving his opinion that the injuries were deliberately inflicted, no further action was taken after an assessor visited the family home but without actually seeing Blake.
The review said this hospital admittance was a particularly “significant missed opportunity”.
When the case was re-investigated last year, Hampshire police’s Assistant Chief Constable Laura Nicholson apologised “that the initial investigation by the constabulary was unsatisfactory”.