Social work consultant Jimmy Hawthorn said it had been “reasonable” for the meeting, called an initial referral discussion, to conclude that a child protection assessment was required and a plan put in place to support the children.

But no arrangements were made for the various agencies to keep in touch, no minute of the IRD was produced and it was “unclear” what expectations the participants had about what action would follow.

Mr Hawthorn concluded that the IRD, held on February 28 last year, “lacked proper co-ordination or direction and nobody was identified from the meeting to visit the family in the week following.”

Little Brandon was killed by his mother’s boyfriend on March 16.

Mr Hawthorn’s report goes into extensive detail about the contact Brandon and his family had with social workers and other agencies in the time leading up to his death.

He has said that “the violence of Robert Cunningham towards Brandon Muir could not have been predicted”, but he is critical of the way aspects of the case were handled.

His significant case review said, “In the period of less than three weeks that Cunningham became part of the family grouping with Heather Boyd and her two children, child protection staff had quickly embarked on a process of assessment and information gathering which would have led to a case conference on March 18, 2008.

“In that time, both social work and health staff had seen Heather Boyd, Robert Cunningham and the children on a number of occasions, visited the home, and Heather had cooperated with a medical examination on Brandon in relation to a query about his gait.

“The focus of attention in preparation for the case conference centred more on the well-being of the children against the context of concern about Heather Boyd’s wider parenting skills and the home environment, rather than the threat of violence from Robert Cunningham.”

Mr Hawthorn said the authorities had sought to offer Heather Boyd support in her parenting role. She never utilised this to any great degree, preferring to make use of the support offered her by her parents.

While she had come to the notice of the police in the past, nothing was known of her activities in prostitution, and she had no recorded history of drug misuse.

Experienced staff found no evidence of either a chaotic household or lifestyle that suggested she had a dependence on substances.

Mr Hawthorn said, “Both health visiting and social work staff consistently stated that Heather and her children did not stand out as giving great cause for concern.

“Whilst there were ongoing concerns, these never reached a threshold which prompted consideration of more formal intervention, until shortly before Brandon’s death.”

He has concluded the case raises questions about the evaluation and sharing of information between agencies, the need for full background checks on all household members, the conduct of initial referral discussions and the impact of domestic abuse and substance misuse on children.

He said, “In the short three-week period when Cunningham resided with Heather Boyd and her children, the authorities, while active in personal engagement with the family, were not able to assemble, process or assess all the available information on Boyd or Cunningham.

“The inquiry revealed gaps and inaccuracies, some caused by pre-existing systems, others by a lack of available resource.

“While Brandon’s grandparents immediately raised their concerns, and prompt action was taken to discover what was known about the developing circumstances of Heather Boyd, her children and her new partner, the significant case review concludes there was little opportunity to prevent the fatal assault on Brandon, from which he subsequently died.”

Mr Hawthorn noted that he had interviewed 48 staff who had been involved in the case, each of whom had been, in his view, candid and honest in their comments.

“It is clear these are committed professional people, often working under a real sense of pressure. I was impressed by their determination to learn any positive lessons from the review for their future practice.”

He also praised the “enormous integrity and dignity” of Heather Boyd’s parents, who had been his main family contact during his work.

The consultant explained, “This case is highly unusual and unlike many other child death inquiries in that the sustained inter-agency involvement with the family was confined to the three-week period most important up to Brandon’s death — an extremely short timescale.

Although there had been a “prompt” response to concern expressed by Brandon’s grandparents, Heather’s attitude towards social workers and her parents had become “more oppositional” due to the increasing influence of Robert Cunningham over her. She had been “smirking and dismissive” during a meeting on February 27, the day before the initial referral discussion.

The IRD had been convened at short notice and did not have all the relevant information available. That included extensive police details about Cunningham, such as his recent assaults on his former partner.

There was further contact with the family after that. A family support worker on March heard, but did not see, a loud slap. Brandon was later seen on the floor crying and his mother had not made eye contact when the worker had sought an explanation.

Two more staff made an unannounced home visit on March 11. Brandon had a graze level with his eye and he and his sibling were both exhibiting “inappropriate clinginess and attention-seeking.”

On March 13, the final official contact with the family took place, when Heather took Brandon to a drop-in clinic. The GP later told Mr Hawthorn that the toddler had sat on her knee rather than go to his mother who was nearby.

The next day Cunningham phoned police HQ and the council’s access team social worker to complain angrily he had been slandered by social work staff, who had shared details of allegations of his criminal behaviour with Heather. Two days later Brandon was dead.

Mr Hawthorn said, “The workloads of the health visiting team and the social work access team throughout the period were high. They also both faced significant staffing pressures and vacancies. Details on Heather’s lifestyle and domestic circumstances were scant.

“On the single occasion when I met her, she described as her greatest regret that she had not asked the social work department for help and support when she was experiencing difficulties in her relationship with Brandon’s father. She said she had not asked for fear that her children would be removed from her.

“All of this serves to highlight the fact that statutory agencies are dependent upon receiving and sharing information if they are to act to protect vulnerable children who may be at risk. At different stages of involvement with agencies, Heather appeared to cooperate and accept agencies’ concerns. With hindsight, this was only partial compliance, and there was no robust managerial oversight or supervision in place to challenge workers’ optimism.”

He said that if full information from the police and social work had been available to the IRD, this may have led to more pro-active involvement with the children. But that was speculative, and said only with the benefit of hindsight.

“Whilst staff who attended the IRD recalled there were no alarm bells ringing, they also recognised the attempts to engage Heather voluntarily had been unsuccessful, hence their unanimous decision to convene a child protection case conference.

“I think there would be merit in reconsidering the management of those IRDs where there is no specific incident, but concerns based upon changes in family circumstances. In these instances, more senior personnel from the relevant agencies should become involved to ensure greater oversight and objectivity of the family’s circumstances.”

He said the lack of any substantive information about Cunningham was particularly telling.

“Although his short involvement with Heather and her children had such far-reaching and tragic consequences, little of any substance is known about him, his past, or his previous relationships. He remains a shadowy figure throughout this report.

“There was nothing that stood out from the events of the last weeks of Brandon’s life which could have signalled the violence he was to suffer. There were no indications of the likelihood of a significant violent occurrence. The only indication of this came from post mortem, when the full extent of Cunningham’s violent outburst was apparent.

“From my extensive consideration of information from records, from scrutiny of policies and procedures, and from discussions and interviews, I have reached the conclusion that Brandon’s death could not have been predicted.”