A "catalogue of serious failings" at a charity exposed vulnerable children to harm, a Government watchdog has found.
An investigation into the The Royal National Institute of Blind People found serious issues with the organisation's Pear Centre children's home in Coventry, which put children with complex needs at risk of harm and distress.
On one occasion, a child at the centre suffered an increase in epileptic fits after they attended a medical appointment where their medication was altered.
The child's parent who usually attended appointments could have told a doctor that this new medication was known to make the child's epilepsy worse, but they were not told that the appointment had been scheduled.
Another child did not get new boots for three months, despite shoes that were too small, causing them injury.
The investigation into the charity was launched in March 2018 by the Charity Commission after concerns were raised about the children's home and education regulator Ofsted issued a notice of intention to unregister the facility.
The reviews found a "culture that was too insular and dismissive of external criticism from Ofsted, CQC and parents" as well as poor staff training and recruitment and a "disproportionately high number of basic medication errors".
According to the independent commission, many children at the Pears Centre had needs and disabilities so complex that their placement there could be an alternative to a hospital stay.
The boss of the Charity Commission called the findings "one of the worst examples we have uncovered of poor governance and oversight having a direct impact on vulnerable people".
Helen Stephenson said the "catalogue of serious failings were allowed to occur, because the charity's governance was simply too weak for the trustees in charge of the charity to do the job that beneficiaries needed them to do".
She added: "No child should ever be put at risk of harm and this case is all the more troubling because it happened in the care of a charity."
The chief executive officer of RNIB has apologised for the findings, which he says "represents the low point in our 152-year history".
It is clear that we seriously let down children and their families, staff, volunteers, supporters and blind and partially sighted people who make up the RNIB community. We are sorry to every one of them.
He says the charity is working to implement the report's recommendations and is making "good progress".