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
Luke Castiglione has the latest weather forecast. Cloud with rain this afternoon, becoming dry and sunny tomorrow
Luke Castiglione has the full forecast. Showers drying up but further rain on the way....
Friends remember "amazing" Adam Pritchard, who died after apparently plunging down down a sharp drop while cycling with his sister.