The events leading up to the death of a Carlisle child known to social services were not investigated properly, say government inspectors.
An inquiry into the care given to a little boy before he died in a house fire in August 2006 has been deemed inadequate by Ofsted, the News & Star has discovered.
Ryan McHale, four, had been led to safety from a blaze at his grandfathers Currock Road home but he ran back in to reach his dad who lay comatose in the bedroom after drinking cider and smoking cannabis.
His grandfather tried to rescue him but as Ryan was shouting dad, dad he was beaten back by the heat.
After an inquest in February 2007, North East Cumbria Coroner David Osborne delivered a verdict of accidental death.
Mr Osbourne went on to raise very serious concerns about the fitness of Ryans parents particularly father Sean who was said to be a regular cannabis smoker.
At the time of his death Ryan was being monitored by Cumbria County Council childrens social care, Cumbria Constabulary and Cumbria Primary Care Trust.
The board set up to oversee protection of the countys children launched a serious case review to see if any lessons needed be learnt from the tragedy.
But Ofsted found Cumbria Local Safeguarding Children Boards report (CLSCB) lacking in a number of areas.
The quality of the analysis of some of the county council, police and PCT internal reviews was not up to scratch.
Neither was the action plan CLSCB had drawn up to address the failures it had uncovered in the system.