A baby boy, who travelled with his mother from Birmingham to London, was found dead after having starved for several days despite being under the care of at least nine doctors, social workers and health visitors.
The emaciated body of the 10-month-old, the son of an HIV-positive woman, was found in his family flat in north-west London, on March 8.
His 29-year-old mother, who had moved to London from Birmingham last September, was arrested on suspicion of child neglect but died two days later from a rare brain condition linked to her medical condition.
A post-mortem examination earlier this month has not yet fully established a cause of death for the baby boy and officers are waiting for further test results, Scotland Yard said.
But an internal management review by one of the health trusts involved, Central and North West London NHS Foundation, leaked to the Daily Mail, said: “Post-mortem results on the infant showed that he had no food in his gut at all and so had not eaten for several days at least.
“However, there is evidence of a long period of malnourishment.”
A serious case review has been launched into the circumstances surrounding his death.
The boy, who was said to have had “massive” developmental difficulties, an underlying serious health condition and a history of being underweight, is reported to have been seen at least 15 times in the last six months by care professionals.
The agencies involved in the case are said to be two health care trusts, Westminster City Council social services and a consortium of London boroughs providing health visitors.
Westminster council said the baby boy and his three-year-old sister were not on the child protection register.
The family were said to have been rehoused in London after the mother claimed she was beaten up by the children’s father.
The Daily Mail said the mother avoided contact with care workers by claiming that using a interpreter to question her could breach her confidential status as HIV positive.
Terry Bamford, chairman of Westminster Local Safeguarding Children Board, said: “This is an extremely tragic case and our thoughts are with the surviving family members.
“A serious case review will now be conducted by somebody completely independent of all the agencies who had contact with the family.
“The review will look into several aspects of this complex and challenging case, many of which are still unclear at this early stage.
“Police inquiries and medical investigations are still ongoing so speculation surrounding this or the role of any individual or agency is not helpful.
“When we have investigated the full circumstances that led to the baby’s death, we will be able to determine if anything could have been done to help prevent it. The review will make recommendations if any changes in policies and procedures are necessary”.
He rejected a “misleading impression” that there were no lessons to be learned from the case.
“I think that virtually every serious case review finds that there are lessons to be learned, often, sadly, lessons learned with the benefit of hindsight,” he said.
Michael O’Connor, Westminster council strategic director for children and young people, said: “The family was new to London and the council had arranged their housing.
“They were under the care of the health service, and social services were working closely with health professionals to help support them.
“Neither of the children were on the child protection register and there is no suggestion that they were at risk of harm from neglect or abuse.
“We do not know the cause of the baby’s death yet, and until we do we will not be able to determine if anything further could have been done to help prevent it.
“This is one of the saddest cases I have ever come across, and our thoughts are with the surviving family members who we are supporting at this difficult time.”
A Scotland Yard statement said an inquest into the death of the boy opened and adjourned at Westminster Coroner’s Court last week.
It said a post-mortem examination had not yet established a cause of death for the mother but her death was believed to be linked to “existing illness” and was not being treated as suspicious.
“The matter has been referred to directorate of professional standards and the Independent Police Complaints Commission as is routine,” the statement said.
The news of the death of the baby boy comes after the mother and stepfather of Khyra Ishaq were jailed earlier this month for her manslaughter.
The seven-year-old died in May 2008 when her body succumbed to an infection after months of starvation at her home in Handsworth, Birmingham.
Nickie Aiken, Westminster Council cabinet member for children and young people, said: “There was never any suggestion given to us that the baby was at risk of abuse or neglect.
“There were a number of serious health issues affecting the whole family and the baby had serious developmental issues.
“As far as I am aware, at least nine NHS professionals were working with the family and I hope that no stone will be left unturned to find out exactly why this child died.
“I have been assured by my officers that there was no reported risk of abuse or neglect in this case.
“But I want to know why this child was being seen by nine NHS professionals and why things were not flagged up earlier.
“As a mother of two young children myself, I can only imagine the tragedy in this case.”