Inquests into the deaths of the 30 Britons, including four from the West Midlands, killed in the Tunisia beach massacre of 2015 will begin today.
Failings Over Birmingham Toddler's Death
A serious case review's found there were failings in communication and missed opportunities to intervene by health and probation services in Birmingham and East Midlands after a 3-year-old boy was battered to death.
The final report said there had been ''a loss of contact with agencies, hindering effective inter-agency communication'' according to Birmingham Children's Safeguarding Board (BCSB).
Peter Cawser, formerly of Edward Street, Albert Village, Swadlincote, on the Derbyshire/Leicestershire border, was jailed for life with a minimum term of 18 years, after admitting murdering his girlfriend's child Dylan Crean by battering him to death.
The report, published on behalf of the Local Safeguarding Children Boards of Derbyshire; Leicestershire and Rutland; Birmingham and Nottingham City, said the ''transient lifestyle'' of the boy's mother - moving between ``numerous addresses'' in Birmingham - had led to a loss of contact with probation and mental health services.
The children's social care team in Birmingham did not know the child and his mother had moved to Derbyshire and later Leicestershire, where they had moved in with Cawser.
The case review uncovered ''a missed opportunity'' by the team to assess the child's needs after Dylan was taken to hospital with a dog bite seven months before he was murdered.
In particular, the report identified a need for improvements at both Derbyshire Probation Trust and Derbyshire Healthcare NHS Foundation Trust, Adult Mental Health Service.
The review stated: ''Both mental health services and the probation trust were aware of the presence of a child in the same household (as Cawser) but there was no contact or exchange of information between them''.
Despite probation services classifying Cawser as ``of medium risk to the public'' no action was taken to refer the matter to the local children's services team for further assessment.
The report stated: ''The 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.''
Cawser, whose own family had warned of his ''volatile behaviour'', was also referred to a community psychiatric nurse whom he was quoted as telling in the report that he had ''a Jekyll and Hyde character - fine one moment and agitated the next''.
The nurse gave him contact details for an anger management group, but otherwise referred him back to his own GP, whom expressed concern at this conclusion.
The report went on to state that the improvements identified by the serious case review team had been or were in the process of being implemented.
Jane Held, independent chairman of the BCSB, said : ''It is always with sadness that we publish a review into the death of a child whatever the circumstances.
''It is important to remember at this time that the person ultimately responsible for Dylan's death has been convicted of his murder.''
She added: ''The BSCB will continue to rigorously monitor implementation of the recommendations to emerge from this tragic case to ensure that the learning makes a significant difference to safeguarding children in the future.''
Cawser inflicted more than 70 injuries on Dylan in a sustained and brutal attack which took place in the child's bedroom in August, 2011.
He was taken to hospital, and then transferred to the Queen's Medical Centre in Nottingham where he died from his injuries.
The child and his mother had only moved into Cawser's home the week before the attack.
Sentencing him at Leicester Crown Court in September 2012, Judge Michael Pert QC told Cawser that Dylan's response of ''okay'' to his request telling him not be naughty or make a mess was no defence.
The judge said: ''What happened next was nothing in part to do with the behaviour of Dylan or the behaviour of his mother.
''It was the vindictive and uncontrollable rage of an adult man against a three-year-old child.
''You embarked on a sustained, brutal attack upon this young child.''
Speaking outside court immediately after Cawser's sentencing, Dylan's mother Katie Crean described her son as ``funny, cheeky, crazy, brilliant and beautiful''.
She said: ''I love Dylan so much and miss him so terribly every day.
''My life is so different now and not a day goes by when I don't think of my boy and his lovely smile.
''If you knew Dylan you couldn't help but love him.''
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