Health Ombudsman Julie Mellor has described Sam Morrish's death as a tragic case. She says the 3-year-old was failed by four organisations, and tough recommendations will follow.
She has apologised to the family, and will be meeting them to apologise in person and discuss the case.
More top news
The last pilots to train on Lynx and Sea King helicopters in Somerset have taken part in a parade in front of some special guests.
A teenager has told ITV News how he and a friend braved freezing conditions to rescue a man who had fallen into the River Tamar.
A single mum who was left an anonymous note with a fiver by a stranger on a train has been able to thank her benefactor in person.