Child protection agencies failed a vulnerable and severely asthmatic schoolboy who died alone in "horrendous" circumstances, a serious case review has concluded.
Hakeem Hussain's final moments were spent "gasping for air" after he suffered an asthma attack in the garden of a property he was staying in with his neglectful mother, Laura Heath, a drug addict.
Authorities "could and should have done better" to protect the seven-year-old, who died "needlessly" on 26 November, 2017, a damning review by Birmingham Safeguarding Children Partnership (BSCP), published on Thursday, said.
Heath, 40, formerly of Long Acre, Nechells, Birmingham, smoked three bags of heroin, leaving her in a drug-induced sleep, on the night of the tragedy.
She was jailed for 20 years after being convicted of gross negligence manslaughter following a trial at Coventry Crown Court - where the judge, Mr Justice Dove, blamed Hakeem's death on "catastrophic and deplorable" parenting.
Heath, who spent £55 a day on her drug habit, modified one of Hakeem's inhalers with foil and a plastic band to smoke crack cocaine.
She later contributed to the serious case review saying: "Hakeem should never have been left with me."
Two days before Hakeem collapsed, on Friday, 24 November, a nurse warned a child protection conference he "could die at the weekend".
A social worker agreed to speak to Heath on the following Monday - by which time the "bright and bubbly" boy was dead.
No action was taken over the weekend despite Hakeem's safety being scored as zero out of 10 by a nurse and a family outreach worker at his school, Nechells Primary.
Speaking after her conviction, chief executive of the Birmingham Children's Trust Andy Couldrick conceded there were "clear missed opportunities" to help Hakeem.
Independent chairwoman of the BSCP Penny Thompson admitted that "with the benefit of hindsight", Hakeem's "severe neglect" was "there to be seen well before the decision to place him on a child protection plan".
"Through the serious case review we have learned all those organisations and individuals who came into professional contact with Hakeem could and should have done better," Ms Thompson said.
His school did not intervene despite his "unhappiness and fear of repeated asthma attacks" leading to a marked reduction in his school attendance and performance, the review found.
"In particular, the school did not escalate their concerns effectively, there was a lack of join-up across health service organisations and ineffective discharge for his asthma," Ms Thompson continued.
"The GP did not recognise a need to share important information without consent because of the risk of significant harm."
The social worker prioritised other vulnerable family members at Hakeem's expense, while police failed to identify safeguarding opportunities when responding to incidents.
Hakeem spent his short life battling to get his voice heard amid the competing concerns of his "incapable" mother's drug addiction, serious economic hardship and poor housing.
This, combined with his chronic asthma, "finally proved fatal".
Hakeem father was in prison at the time of his death. Heath's other children were previously taken into care.
Ms Thompson said there have been "significant developments and improvements in services" since 2017.
"We cannot guarantee no child will suffer neglect, nor die from asthma, but we can assure everyone learning from Hakeem's death has contributed to positive and lasting improvements in partnership working for the protection of children."