KEY agencies "poorly managed" the care of a 10-year-old boy who hanged himself in his bedroom, a report has concluded.
Harry Hucknall, a cousin of Simply Red singer Mick Hucknall, was "a sad, lonely and extremely anxious child" but there was no evidence his situation was "demonstrably improved" by the authorities.
The youngster was discovered in his locked room at his home in Dalton-in-Furness, Cumbria on September 19 2010.
He was a twice-removed cousin on his father's side of Hucknall, the frontman for the 1990s chart-toppers.
Last March an inquest heard how Harry was diagnosed with clinical depression and attention-deficit hyperactivity disorder and was prescribed the drugs fluoxetine, an anti-depressant, and Ritalin, a psychostimulant.
He had attempted self-harm and was also the victim of bullying.
A serious case review by the Cumbria Local Safeguarding Children Board was ordered following his death.
Harry, referred to as Child F in the review published today, was first referred to Child and Adolescent Mental Health Services (CAMHS) by his GP in 2007 having been found with a plastic bag on his head and reported to have said that he wanted to die.
He was not seen for psychiatric assessment and instead was offered a programme of undirected play therapy, despite fears being voiced by his mother, the report said.
The youngster was referred back to CAHMS in early 2010 having again been found with a bag over his head and having stated he wanted to end his life.
He was seen by a child psychiatrist who diagnosed a major depressive disorder and at the same time was also referred to children's services by his school. He was then the subject of regular multi-agency involvement up to the point of his death.
The independent report said: "The panel was of the view that Child F's case was generally poorly managed by the key agencies. There was evidence of poor practice throughout, which included both single agency failings and generally poor inter-agency communication and collaborative working.
"Practice was considered to be largely adult rather than child-focused and there was no evidence of Child F's voice being heard or his wishes and feelings taken into account by professionals working with him and his family."
The report added Harry was "extremely vulnerable" and felt "unloved and unwanted", caused by "his parents' inability or unwillingness to recognise his needs and put them before their own".
He was in need of therapy and protection from his parents but neither was recognised or met, despite him being known to a number of agencies.
The report concluded: "It was the view of the panel that no single agency was responsible for failing to protect Child F from the chronic emotional abuse and neglect that he suffered.
"It felt, however, that the failure of CAMHS to identify Child F as a likely high risk of suicide at the second presentation in 2010, produce an accurate formulation of risk and take the lead in developing a multi-agency risk management plan was a fundamental omission which impacted significantly on the responses of other agencies to Child F's difficulties."
Last year West Cumbria Coroner Ian Smith ruled out suicide and, in a narrative verdict, said Harry died as a consequence of his own actions without understanding the true consequences.
The inquest heard that it was difficult to say how the drugs affected Harry's state of mind but their influence could not be excluded. The levels of both drugs found in his system were above the normal therapeutic level for adults.
Mr Smith said he did not criticise their prescription in Harry's circumstances, nor did he argue that the drugs should not be used by children. But he pointed out that doctors must be "extremely careful" in prescribing powerful drugs to 10 year olds.
Addressing the subject, the serious case review found: "The issues in relation to the use of such medication and the complexities involved in treating co-morbidities remain unresolved. This is clearly a national issue and central government guidance is needed to inform and direct future medical practice."
In a statement, Cumbria Local Safeguarding Children Board said all agencies involved "deeply regret that this tragic event happened".
It continued; "The report makes a number of different recommendations for how we should all improve our practice. Many of these relate to issues around how agencies assess the needs of children and in particular how they respond to evidence of self-harm or threats of suicide in children.
"We believe the key lessons which are common to all agencies are: the child must always be at the centre of our work and should be asked directly about their care and their feelings; we should always take threats of suicide seriously - this applies not just to agencies and professionals, but to families and communities; multiple medications to children should be carefully prescribed and monitored.
"Full and comprehensive action plans have been produced in line with the recommendations of the review. Cumbria Local Safeguarding Children Board will be overseeing progress on these plans, and holding the agencies to account for completing them.
"Many of the actions have been implemented, and the remainder are well on their way to completion. The changes made will improve the quality of services provided to children and families in Cumbria."