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31 October 2014, 15:41 | Updated: 30 March 2016, 13:50
A nine-year-old from Teesside found hanging in his bedroom had suffered neglect, witnessed domestic abuse and his family had been involved with different agencies for years, a serious case review has found.
The British champion junior wrestler, only named in the report as Gavin, had a sad face even when he was happy, his head and deputy head teacher reported.
He was found unconscious in his bedroom by a younger sibling in August last year and died nine months later. When paramedics attended there were no lights upstairs and they had to fetch a bulb from downstairs.
The sports mad boy, from Stockton had suffered from Attention Deficit Hyperactivity Disorder (ADHD) and went to a local special primary school.
Gavin and his family had periodic involvement with different agencies in Stockton including Health, Social Care, Education and Police, going back to 2005, and before this with social services in Durham.
He had been the subject of a child protection plan on three separate occasions due to neglect, although at the time he was found hanging he was not on one and the family were not involved with Children's Services.
He had been briefly fostered in 2006 over concerns about neglect and domestic violence in the home.
His school raised questions in May last year about his ``unkempt'' appearance, and staff reported he appeared withdrawn and malnourished. His bad body odour was later found to be caused by the family's broken washing machine which was not quickly replaced.
Described as a ``beautiful singer'' and popular with classmates - although he did not think he was - Gavin had no history of self-harm and his death was not preventable, the Serious Case Review found.
``However, the review has highlighted a number of missed opportunities to safeguard Gavin over time and has revealed areas where professional practice across some of the agencies involved could be strengthened and improved,'' Mike Harrison, the report author concluded.
One issue raised was that the child protection plan for Gavin was halted too quickly, with ``insufficient questioning about whether significant improvements had been made in Gavin's home situation''.
The Independent Chair of the Stockton-on-Tees Local Safeguarding Children Board, Colin Morris, said it will never be known why the child died.
``'Gavin' did not have a history of self harm.
``The independent review is clear that the events which occurred that day could not have been anticipated by any of the professionals or agencies who were or had been involved with 'Gavin' and his family.
``In the independent author's view, the incident was not preventable.
``The purpose of a Serious Case Review is to ensure that lessons are learned and the independent author has made a number of recommendations to improve multi-agency working.
``Some of these recommendations have already been implemented while a number of others are well under way.''
Deanna Neilson, head of safeguarding for the charity Action for Children, said:
``This is a very sad case of a deeply troubled child, who endured shocking neglect during his all too short life.
``While the serious case review says professionals could not have predicted the boy's death, the case does draw attention to the impact emotional as well as physical harm can have on children.
``Violence in the home, even when directed at someone else, can cause life-long mental health problems and, in extreme cases, can lead children to self-harm or even suicide.
``Emotional abuse is not only as harmful as physical abuse, it is more prevalent, as the most common reason for a child protection referral.''