A review into the death of seven-year-old Hakeem Hussain has found there were failures in the opportunities to intervene and prevent his death.
The review, published by the Birmingham Safeguarding Children Panel, reveals those who came into professional contact with Hakeem, including his school, GP, police and his social worker should have done better.
Hakeem, who was known to authorities, died alone and "gasping for air" in the garden at the home of a friend where his mother had been staying.
The jury was also told she had repurposed one of his inhalers as a makeshift crack pipe.
On the night Hakeem had died, Heath had smoked heroin before passing out in the same bed as him.
Unable to wake his mother, it is thought he then went outside for fresh air, where he was found the next morning, still clutching a leaf.
ITV News Central has pulled out a number of key findings raised in the review concerning Hakeem's case.
Failure by all who came into professional contact with Hakeem
Professionals did not communicate sufficiently between one another or inform the birth father of growing concerns for Hakeem's welfare.
The review notes of the "the failure by all agencies to consult and inform the birth father of the growing concerns for his son’s welfare resulted in professionals not adequately taking account of his ethnicity and background".
Agencies also did "not adequately take account" of the potential for "extended family support or wider engagement and support from the family’s wider community".
Lack of communication between Hakeem's school and social care
The serious case review confirms there was a lack of join-up and communication between those responsible for Hakeem’s school absences and children’s social care.
This resulted in the two processes not taking account of the neglect that Hakeem wasexperiencing.
Limited understanding of what daily life was like for Hakeem
Professionals had only a limited understanding of what daily life was like for Hakeem. This resulted in a lack of assessment of what his reality was like through the day and night and the level of neglect experienced.
The short time for developing a relationship and engaging with Hakeem in assessments and visits limited the scope to establish trust.
Going forward, the review states "it is essential that supervision processes and multi-agency assessments are required to clearly describe a day in the life of each child".
Lack of professional awareness around asthma
The review has found that there is a lack of professional awareness around the appropriate use of medication for children with asthma.
It added that this can result in a failure to identify patterns of over-prescribing of inhalers and use of asthma medications that may indicate parental drug misuse.
Confusion by professionals around significant harm
Where a child has a chronic medical condition that is being poorly managed by a parent, the review found there was confusion by professionals around significant harm thresholds for neglect.
There is a need for professionals to become more aware of the correlation between poor parental management of medication for children with chronic health conditions such as asthma and wider childhood neglect.
How has the Birmingham Safeguarding Children Panel responded?
In a statement, the independent chair of the panel, Penny Thompson said: "On behalf of the Birmingham Safeguarding Children Partnership I want to start by expressing the sincere sadness felt by all partners at the awful death of Hakeem, almost five years ago.
"The passage of time has not damped down our feelings, but it has given us time to genuinely reflect, inquire and learn from the events of Hakeem’s often sad life and untimely and unnecessary death in 2017.
"We have used the time to act on that learning. As we know, Hakeem’s mother is now serving a very long prison sentence for the manslaughter through neglect of her seven-year-old son.
"However, through the Serious Case Review we have learnt that all those organisations and individuals who came into professional contact with Hakeem could and should have done better. Once again, we have a tragedy of a child dying from asthma.
Ms Thompson continues: "This is not inevitable or acceptable. Clearly Hakeem’s mother should have provided much better care for his serious condition.
"Now, asthma sufferers should have an Individual Asthma Management plan which is reviewed annually by an experienced clinician.
"With the benefit of hindsight, the extent of Hakeem’s neglect was there to be seen well before the decision to place him on a Child Protection Plan two days before his death.
"It is horrendous that Hakeem unhappiness and fear of repeated asthma attacks, some of which required hospital admissions, and the marked reduction in his attendance and performance at school, did not trigger more effective intervention."
Ms Thompson adds: "In the intervening five years since Hakeem’s death in 2017, a lot has changed.
"All agencies acted quickly to improve their own practice and embed emerging learning from the review, whilst finalisation of the review and publication was delayed until the outcome of the criminal proceedings.
"There has also been significant developments and improvement in services for children and families in Birmingham, with the Police, NHS and Local Authority now having equal statutory leadership responsibility for the multi-agency safeguarding arrangement through the Birmingham Safeguarding Children Partnership."