A four-year-old child became trapped between two stairgates and died days after a health visitor reported “filthy conditions” and “squalor” at his home.
A serious case review found the child, known as AH, died in April 2019 following a cardiac arrest three weeks after the accident at his Norfolk home.
There was often no food in the house and children were left in soiled nappies, the report said.
Agencies involved are to re-examine how they assess neglect.
The review by the Norfolk Safeguarding Children Partnership (NSCP) found a number of “concerns about neglect” were known by agencies during Child AH and their siblings’ lives.
Despite this, it was decided the family did not meet the threshold for a social work assessment.
‘Filthy home and garden’
The accident, on 3 April, took place while AH and three of the child’s four siblings were at home, the Local Democracy Reporting Service said.
Police who responded to a 999 call said the house was in “absolute squalor”.
The report said: “Child AH was found trapped in the gap between the original stairgate and one added to prevent the children climbing over the lower one.”
In March, the family was referred for family support services by a health visitor, who noted “the filthy condition of the home and garden, the safety of the children, and the risks presented by the stairgate”.
However, they were “happy, lively and resilient” with a “warm relationship with their mother who clearly loved them”, the report added.
Professionals felt AH’s mother was “overwhelmed by demands of a big family, a low income and no friends or family support”.
AH’s siblings have now gone into foster care or are being looked after by the council.
Chris Robson, NSCP chairman, said: “This was a tragic accident. AH’s mother was seeking to protect him by installing these gates.”
The review made six recommendations on how agencies could improve assessments of need for support.
Mr Robson said “more could have been done” in this case.
He added: “Used in the right circumstances, there is no doubt that stairgates save lives.”