A very serious failure by social services might have led to the death of Gravesend schoolboy Edward Barry, a damning new report has revealed.

Edward, known as Ed, was found dead at a flat in Parrock Street in November 2009.

The Gravesend Grammar School pupil, of Pelham Road South, Gravesend, died as a result of the combined effects of methadone and diazepam intoxication.

Now a 48-page report has been published by the Kent Safeguarding Children Board, looking into how he died - despite coming to the attention of numerous support agencies.

It criticises the way Kent County Council's Children's Social Services (CSS) department handled Ed's case in the months from February 2009 to his death on November 20 that year.

The serious case review, which refers to Ed as 'Daniel' as KCC say it is required by law to anonymise serious case reviews, said: "There was a fundamental failure to grasp the responsibilities of CSS. The thresholds for intervention were far too high. They were not based upon the child's welfare or the significant harm that Daniel was known to be suffering.

"From June onwards there was no adequate plan to protect Daniel from harm due to his increasingly dangerous risk taking behaviour. This was a very serious failure by CSS."

It added: "CSS should have been the lead agency in this case at least from June onwards when it was undeniable that Daniel was suffering or likely to suffer significant harm.

"The result of not taking lead responsibility and using it effectively was that there were a number of missed opportunities for effective multi-agency working.

"Many opportunities to assess this young person's needs were missed and his immediate need for protection was repeatedly left unaddressed.

"Some professionals, notably the school, Child Adolescent Mental Health Service (CAMHS) and the worker from the Adolescent Resource Centre provided him with the opportunity to be heard and his school was vigorous in advocating for him.

"However, when they encountered resistance from CSS they proved ineffective in challenging this."

A verdict of misadventure was ruled in March after a near three-week inquest at Gravesend's Old Town Hall.

An inquest was originally opened in May 2010, but delayed when the case became embroiled in a row between KCC social services and the coroner.

The report concluded work "needs to be undertaken to ensure effective working between CSS, the police, CAMHS, and schools in this district".

Maggie Blyth, chairman of Kent Safeguarding Children Board (KSCB), said: “Daniel died in tragic circumstances and I would like to offer my sincere sympathies to his family and friends.

"In the months leading to his death, several agencies were involved in working with Daniel and his family. KSCB commissioned this serious case review in 2010 to look in detail at the way the services worked together and identify any lessons that can be learned for the future.

"The report concluded that by July 2009, Daniel's behaviour and the risks he was exposed to were continuing to escalate and it was reasonable that the agencies involved should have been aware of that and responding appropriately."

The review concluded there could be no certainty that his death could have been prevented.

However, the review also concluded that had the agencies followed procedures and worked more effectively together to complete a better assessment of his needs it may have lead to a different outcome.

It said: "In the three years since Daniel died, Kent County Council's children's services, Kent Police, the NHS in Kent and Medway and Daniel's school have been working to establish more effective co-operation. KSCB has been encouraged by the changes these agencies have made following recommendations."