An inquiry into the death of a two-year-old boy who inhaled fumes from his addict mother’s drugs and sucked empty methadone bottles has found lessons must be learned.

The grandson of Bradford playwright Andrea Dunbar died after breathing in passive smoke from heroin and crack cocaine.

Samaya Rafiq, also know as Lorraine Dunbar, was jailed for four years last November, after a court heard she allowed her son Harris to play with empty bottles of the heroin substitute.

The two-year-old developed a craving for methadone and was seen to scream and hold out his arms while his 28-year-old mother was taking her dose.

Harris, whose name was placed on the child protection register at birth, was killed by methadone poisoning after ingesting the equivalent of a teaspoonful of the prescription drug.

An investigation into the way agencies handled the case has found there was not a consistent focus on the effect Rafiq’s lifestyle had on her ability to look after her son.

The report states: “In working with families, agencies need to give attention to all desired outcomes for children, not just safeguarding from neglect or harm.

“The serious case review makes a number of recommendations to address this, in relation to content and audience for training.

“While all agencies were vigilant in monitoring for neglect or harm, no assessment had been carried out to mitigate the risk of him being actively given prescription drugs.”

And it stresses: “The frequency of agencies’ contact with HD and his mother was at an appropriate level, and the agencies’ specific focus on HD’s safety was clear. The serious case review found professionals visiting and observing HD could not reasonably have been expected to recognise that HD was ingesting methadone.”

The serious case review by Bradford Safeguarding Children Board has found the level of partnership working between agencies was good but ways have been identified to improve the exchange of information. A number of recommendations have been made and these were due to be discussed by Bradford Council’s Corporate Parenting Panel today.

Board chairman Kath Tunstall said: “Sadly, very little could have been done in this case, but all the agencies have started to address the recommendations in the report. Detailed action plans have been drawn up which we hope will reduce the risk of something like this happening again.”

Rafiq pleaded guilty to manslaughter by gross neglect and four charges of child cruelty by allowing him to ingest drugs, including cocaine, heroin, methadone and a sedative.