There were "clear missed opportunities" by social workers ahead of the death of a severely asthmatic boy in Birmingham, according to a child protection chief.
Drug addict Laura Heath, 40, has been jailed for 20 years for the gross negligence manslaughter of her seven-year-old son Hakeem Hussain.
The young boy died alone in a garden "gasping for air" without his inhalers on November 26, 2017.
Heath had previously admitted four counts of child cruelty ahead of a three-week trial at Coventry Crown Court, including failing to provide proper medical supervision and exposing Hakeem to class A drugs.
The court heard that two days before Hakeem's death, social workers voted to act to protect Hakeem, at a child protection conference.
The meeting ended with an agreement that the family's social worker would speak to Heath on Monday - by which time Hakeem was dead.
School nurse Melanie Richards, who gave evidence at the trial, said she told the conference meeting Hakeem "could die at the weekend from asthma."
Neelam Ahmed, family outreach worker at Hakeem's school, also told jurors how she had voted at that same meeting "to take Hakeem immediately in to care."
A serious case review is under way into all agencies' contact with Hakeem and his family, to be published within weeks.
Birmingham Children's Trust took over the city's social services in April 2018.
Speaking after the trial, the trust's chief executive, Andy Couldrick, said the child protection conference "should have happened earlier" and there were "some clear missed opportunities" in the case.
Hakeem's death came just months before responsibility was transferred from the council's failing child services department, after years of poor performance including the high profile deaths of Khyra Ishaq in 2008, Keanu Williams in 2011, and Daniel Pelka in 2012.
Mr Couldrick said: "I think that, for too long, social workers worked in what they believed was partnership with the mother, and didn't understand the amount of disguise and deception in regards to her substance use, in particular, and Hakeem, who had an additional area of vulnerability because of his asthma."
"I think different agencies and services connected with Hakeem didn't do enough to seek information from each other and share that information.
"If all of the necessary information is being shared... I think a different picture emerges."
He added: "At the sharpest point was the child protection conference on Friday before the weekend of his death."
"The conference should have happened earlier.
"And in any conference where there is such a serious level of concern about the risk to the child, it should have led to more immediate action.
"The serious case review may shed more light, but I am assuming there must have been a consensus at the end of the conference that meant there wasn't immediate action taken.
"That's one thing that has changed in the way we do business."
Asked if vulnerable children were safe in Birmingham in 2022, Mr Couldrick said: "These measures are stronger in Birmingham than they were five years ago.
"I think we will never be able to completely eradicate the risk of tragedies like this happening, because people go on finding ways of doing seriously harmful things to small children.
"The least we can do, reduce the risk to the lowest level possible... the way we have since the Trust started."
He added: "We ask social workers to judge when the right time is to remove a child.
"We want social workers to get that right.
"Most of the time social workers do that well - and sometimes get it wrong."
"I think child social care in Birmingham did do some things wrong (in this case) and we have worked hard to learn those lessons," he added.
"Because every time we let this happen, we lose social workers.
"I hope we can be humble about the things which have gone wrong, and learn better from that and be confident to put things in place to make Birmingham Children's Trust a safe place to learn and become stronger social workers."