Tyler Whelan death: Agencies 'missed chances'
Child protection agencies missed "numerous opportunities" in the care of a five-year-old boy murdered by his mother's partner, a report has said.
Tyler Whelan's mother, Stephanie Whelan, 27, was found guilty of allowing or causing the death of her son.
Her former partner, Elvis Lee, 34, was convicted of the murder at Cambridge Crown Court.
A Serious Case Review found child protection procedures had failed.
Tyler died in hospital in March 2011 after collapsing at home in Peterborough.
He was not subject to a child protection plan, the Peterborough Safeguarding Children Board report said.
The report examined the role of Peterborough Children's Services department, medical professionals, Cambridgeshire police and probation officers.
It found an assessment of the family carried out by a social worker was "very poor" and had not met "procedural requirements".
Lack of 'curiosity'
The report identified "numerous missed opportunities when interventions should have been more rigorous and incisive or clear".
But it said there was no evidence that the death could have been prevented.
"Overall, concerns and incidents were seen in isolation, with minimal attempts to link concerning patterns of injuries, to enquire in more detail about their cause and nature, and to gain a collective view of family life," the report said.
"Similarly, no satisfactory link was made with domestic violence and the risk to children in the family."
The report found there were a "number of occasions when concerns were raised" about Tyler's care.
But it was "concerning that no professional ever recorded seeing him in the family home".
It said people involved in the care of Tyler had displayed a "lack of professional curiosity" but stated that criticism did not only apply to social workers.
Report author Ron Lock, former regional head of child protection services at the NSPCC, said: "It was concerning that there were occasions when child protection procedures were not followed and when established processes, such as strategy meetings, were sometimes dealt with in an ad hoc way.
"Inter-agency communication at times of clear child protection concerns was also sometimes confused and lacking in formality."
He added: "There was also a sense that a professional rule of optimism existed at times when there was not the evidence to support such a stance."
In February 2010, Peterborough's Children's Social Care department was alerted to a probation service report that said Tyler was at "risk of serious psychological harm" and could be "physically harmed unitentionally".
A neighbour made an anonymous call to the department four days later "expressing concern" about the family.
Tyler suffered a broken leg in June 2010 and about four months later sustained injuries to his genitals.
The injuries represented a "missed opportunity for a more incisive investigation", the report said.
Malcolm Newsam, interim executive director of Peterborough City Council, accepted its social care department had "missed opportunities".
He said: "The service we offered Tyler was not good enough and we offer our sincere apologies to his extended family for that failing.
"There were certainly missed opportunities when intervention should have been more rigorous."
The council said "significant improvements" had been made to its social department, with an extra 25 social workers recruited and workloads cut.