A violent man who murdered a three-year-old boy lived with the child and his mother despite probation and mental health services knowing about his criminal past.
Youngster Dylan Crean died in hospital the day after police were called to a house in Edward Street, Albert Village, north west Leicestershire, after reports a child had sustained injuries.
A serious case review into the death of Dylan, who was killed by his mother's then-boyfriend Peter Gavin Cawser, has found that lessons could be learned by both Derbyshire Probation Service and the county's mental health service.
Both services had dealt with Cawser – who had previously been imprisoned for assault on an ex-girlfriend and displayed "disturbing, volatile, and violent behaviour" - and knew he was living with Dylan and his mum Katie Crean.
Within two days of moving into the house in Albert Village, Cawser had attacked both Dylan and his mother.
Cawser kicked, punched and threw Dylan against a wall, and the youngster died in a Nottingham hospital. He is now serving a life sentence for the boy's murder.
The serious case review found that the probation service and Derbyshire Healthcare NHS Foundation Trust did not communicate well enough over the case in the run-up to Dylan's death.
It said the mental health service had been aware that Cawser, formerly of Woodville, was under a supervision order, and the probation trust that he had been referred for mental health assessment.
The review stated: "Both of these agencies were aware of the presence of the child in the same household but there was no contact or exchange of information between them.
"During the contact with the Probation Trust the perpetrator repeatedly stated his intention to move into independent accommodation with the mother and the child.
"However this did not prompt any enquiry or referral to children's social care to ensure the child was safeguarded.
"The mother was to move to independent accommodation and the perpetrator was to breach his curfew to move in with her.
"Within two days he had violently assaulted both the child and mother."
Dylan was born in Birmingham, where his mother originates from, and it was Birmingham Safeguarding Children Board that launched the review in October 2011.
A statement from the board yesterday said that the "key learning" from the tragedy "focuses on improving sharing within Derbyshire Probation Trust and Derbyshire Healthcare NHS Foundation Trust, Adult Mental Health Services".
It said: "Derbyshire Probation Trust must ensure that where an adult poses a risk of serious harm to others within the same household, that they share this vital information with children's social care to enable action to be taken to safeguard and protect children.
"Similarly Derbyshire Healthcare NHS Foundation Trust must communicate effectively with health visitors where a child under five is known to be living with someone who has been referred for a mental health assessment.
"Twelve organisations contributed to the review process, identifying areas where they could improve services. The board can confirm that all internal actions have been completed or significant progress has been made with agreed target dates for finalisation identified."
Paul Lumsdon, chief nurse and executive director of nursing and quality at the mental health trust said it launched its own "comprehensive review" after Dylan's death, on August 31, 2011.
He said: "We explored all opportunities for learning, and developed an action plan with a raft of improvements to the care and safety of families and young children.
"These are spearheaded by taking forward the national safeguarding strategy called 'Think Family'. This aims to heighten awareness of situations where young children may be at risk of abuse or violence within the family, and to strengthen our practices in terms of assessment and, where necessary, intervention.
"We have further built on this platform by making it now compulsory for all relevant staff and managers to receive a tailored programme of training aimed at improving ways of joint working with partner agencies, including information sharing."
And Jo Mead, chief executive of Derbyshire Probation Trust, said it had "worked hard to implement all learning points from the Review and we are now in a much stronger position to protect vulnerable children from harm".
She added: "Staff across the entire organisation have undertaken additional training on child protection referrals, child safeguarding and assessing and managing risk from domestic violence.
"Derbyshire Probation Trust has implemented a system to manage workloads and to provide working conditions which facilitate inter-agency communication.
"We have strong relationships with our partners in the community and we work effectively together as a result.
"We are determined to have the best possible systems in place to supervise offenders in the community and will continue to work even more closely with all our partners to keep the public safe from harm."
