Social workers and police said to have missed chances to help Dylan Tiffin-Brown and Evelyn-Rose Muggleton

Child protection workers, police and other professionals missed crucial opportunities to intervene before two toddlers known to social services were murdered by men with histories of domestic violence, crime and drug use, an inquiry has found.

Separate reports examined the deaths of Dylan Tiffin-Brown, who was two when he died of cardiac failure after his father assaulted him in December 2017, and Evelyn-Rose Muggleton, who was one when she died in hospital days after being battered by her mother’s partner in April 2018.

The serious case reviews highlighted key misjudgments by staff about the level of danger posed by the men to the two children, and failures to act on warnings that the children were at risk. This happened against a backdrop of chaotic child protection services at Tory-run Northamptonshire county council.

Labour called for the resignation of Northamptonshire’s leader, the councillor Matthew Golby, who was the cabinet member for children’s services between May 2016 and April 2018, over the missed opportunities to intervene to protect the children, as well as the council’s failure to tackle problems in children’s services stretching back to 2013.

The shadow communities secretary, Andrew Gwynne, said: “A decade after the tragic death of Baby P and vulnerable young people are still being failed, a situation made worse by years of government cuts to the services that are there to prevent these tragedies from happening.

“There have been repeated failures in children’s services in Northamptonshire since 2013 and there is now no question: council leader Matt Golby has to go. He failed when he was in charge of children’s services, and he’s failed since taking over the council. The people of Northants need to be reassured that vulnerable children in the county will be protected.”

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Golby said he did not intend to step down. “It is only natural that such tragedies would cause everyone involved in the service at the time to search their conscience and look at their own roles and responsibilities,” he said. “I am truly and deeply sorry for the mistakes which were made and the systemic faults leading up to these awful tragedies.”

He added: “As cabinet member I didn’t have sight of individual social work cases. However, I was aware of the challenges the department was facing at this time and equally was aware of the urgent work taking place to address these.

“I believe I still have so much to give as leader of the council, not least in my determination to put right the mistakes which were made in these awful cases.”

Sally Hodges, the council’s director of children’s services since February, said she accepted mistakes had been made by professionals but that there was no link between Northamptonshire’s financial problems and the children’s deaths. “Our failures were in management oversight, poor quality decision-making and inadequate practice,” she said.

Weaknesses identified in the report were being addressed, she said, and the future transfer of services to an independent county-wide children’s trust would accelerate that improvement.

Keith Makin, the chair of the independent Northamptonshire safeguarding children board, which carried out the reviews, said that, although “serious errors of judgment and poor practice” had occurred, “ultimately it was unlikely that anything could have been done to prevent the single, catastrophic incidents”.

Makin said the cases had happened against a backdrop of political and financial turbulence at the council, which has been declared bankrupt twice in the last 18 months. He said there was “no doubt that these two high-profile cases will raise genuine concerns about some elements of the child safeguarding sector in Northamptonshire at this time”.

He added: “I have to acknowledge that, but I am confident too that significant progress has already been made and continues to be in terms of the learning and process improvements which have taken place since.”

Dylan died after sustaining 39 injuries to his face, neck, torso and limbs, including 15 rib fractures and lacerations to his liver, after a sustained beating at home by his father, Raphael Kennedy, 31, a drug dealer from Northampton. A postmortem examination found cocaine, heroin and cannabis in the two-year-old’s body at the time of his death. Kennedy was jailed for life, with a minimum term of 24 years.

Facebook Twitter Pinterest Dylan Tiffin-Brown. Photograph: Northamptonshire police/PA

Two months before his death, police found evidence that Dylan, known as Child AK in the reviews, was being left alone for long periods by his father in a property where drugs were present. However, safeguarding professionals decided Dylan was not sufficiently at risk of significant harm to warrant an intervention.

The review criticised the multi-agency team’s failure to increase the support for Dylan at that time, particularly in light of Kennedy’s “chronic history of domestic abuse” and repeated drug offences. It noted that “there were certainly more risk factors than protective factors”.

The review said the mismanagement of Dylan’s case should be seen in the context of turmoil in the council’s children’s services department, which was beset by high staff turnover and social worker caseloads, and the failure of managers to accurately identify high-risk child protection cases.

Evelyn-Rose, referred to as Child AP in the reviews, died three days after sustaining traumatic brain injuries from her mother’s partner, Ryan Coleman, now 23, who was convicted of her murder and jailed for life, with a minimum of 17 years. She had received multiple bruising and bleeding injuries, including damage to her spine and both eyes.

The reviews found that, although NHS and school staff had recorded signs that Evelyn-Rose and her four siblings were suffering from neglect, they had failed to share this information. Although Evelyn-Rose’s mother did not engage with safeguarding services, social workers felt she was “parenting well”.

The review criticised social workers for their “over-optimistic” view of the mother’s competence to care for her children, despite a history of emotional abuse and neglect. They lacked “professional curiosity and challenge”, failed to spot the risks to the children and allowed the case to drift before closing it down prematurely.

Coleman, who had a history of violence and drug dealing, and was homeless before meeting Evelyn-Rose’s mother, attacked the girl while caring for her when her mother was at work. The mother failed to spot the dangers, telling the reviewers she had judged Coleman as “a caring, loving person who looked after the children very well”.

Makin said that, in the light of Evelyn-Rose’s death, a national campaign should be launched to make parents aware of the potential dangers of letting a new partner into their children’s lives.

A Department for Education spokesman said the government had put in place a commissioner to drive improvement in the council’s children’s services. He added: “Every single incidence of harm against a child is a tragedy and it is imperative lessons are learned which can help prevent such terrible events.”