Social workers had no contact with a two-year-old Northampton boy in the two months before his death at the hands of his drug-dealing father.
Dylan Tiffin-Brown died days after his second birthday in December 2017. The toddler was found with a high level of class-A drugs in his system, multiple injuries and bruises.
His father, Raphael Kennedy, had only just been confirmed as the toddler's biological parent two months beforehand and was subsequently convicted of his murder.
But a Serious Case Review into the child's death has revealed that the large caseloads being felt by overworked Northamptonshire social workers at the time may have had a contributing factor in the death.
Numerous opportunities were missed to place Dylan at risk of greater harm in the run-up to the murder, even though his father had a criminal record dating back to 1999 and whose home had recently been raided in a drugs bust.
A social worker was allocated to the family in the aftermath of the bust - but the report reveals that no observations of the toddler's welfare were recorded during that time.
Presenting the case review at a Franklin's Gardens press conference today, report author Keith Makin, said: "While we cannot make a direct link between the actions taken, or not taken, between the involved agencies in this child's murder, there were serious errors of judgement made."
In the report, he added that "(Dylan's) safety was seriously undermined with lost opportunities to place him at the centre of any risk analysis."
Raphael Kennedy, currently serving a 24-year term for the murder, only became aware that he was the child's father in September 2017 and informal arrangements were made for him to share the care with the child's mother.
However, in Mid-October Dylan was found at his father's house when police carried out a drugs warrant.
Two days after the drugs bust various agencies held a 'strategy discussion meeting' to ascertain whether the child was 'suffering or likely to suffer significant harm'.
The report says this "failed to fully appreciate the significance of the father's chronic history of domestic abuse and extensive history with the police for drug-related offences."
A so-called section 47 inquiry should have been triggered, it concludes, as there were "certainly more risk factors than protective factors."
But it was not and between October and December, no further assessments of the child were taken. Both parents had, during that time, been into contact with various agencies including Northamptonshire County Council, police and probation.
"Perhaps chief among this tragic case is how agencies need to improve information with their own organisations as well as between partners," added Mr Makin.
The report recommends a further review of training to ensure each agency reviews its guidance, training and procedures so the key message is to “think child or young person.”
It also stresses a need to improve information sharing between agencies where complex parenting arrangements exist, such as fathers with several children living in different households.
The Northamptonshire Safeguarding Children's board compiles serious case reviews in the aftermath of serious incidents involving children to examine what lessons can be learned.
More reports to follow.