The death of a Northamptonshire boy who was on the county council child protection register could have been prevented, a report has found.
"Child E", who has not been named in the report, died in suspicious circumstances in March 2007.
The Local Safeguarding Children Board Northamptonshire (LSCBN) report said too much attention was paid to what the child's family said.
More note should have been given to what he had to say, the report found.
'Focus on child'
Independent chairman of LSCBN Janet Galley said: "The review of this tragic case concludes that the event which caused the death of this child could not have been foreseen.
"However it raises the possibility that, had identified safety risks been addressed, the death of the child may have been prevented.
"It also highlights the need for professionals to focus much more on the day-to-day experiences of the child and the effect long-term neglect can have on children.
"The LSCBN will co-ordinate work to ensure the relevant agencies implement the recommendations and continue to put the welfare, safety and protection of children and young people at the centre of their work."
Its recommendations include that:
- Health staff in contact with children should record relevant details and include full consideration of the child's experience
- All midwifery staff need to recognise the importance of working with mothers to use a risk assessment form addressing wider social and environmental factors
Paul Burnett, Northamptonshire County Council director for children and young people, said: "This was a tragic event resulting in the death of a small child.
"Nobody could have foreseen the event which claimed this child's life.
"However, the serious case review raised concerns about a lack of progress with the case and about the extent to which the effects of neglect were understood.
"As a result, we have introduced a number of changes. We've created a neglect assessment tool to help our staff work with families when neglect occurs."
The LSCBN said it would not be revealing any more details about the case as this might lead to the identification of the boy.