A report into the death of a boy placed with a couple who were later convicted of feeding him salt has said there was no way of predicting what happened.
Christian Blewitt was placed with the couple in 2002
His prospective parents, Ian and Angela Gay, were convicted of three-year-old Christian Blewitt's manslaughter in January, and jailed for five years.
The youngster died in hospital in December 2002 after falling unconscious at their Bromsgrove home.
But the report said the situation could have been monitored better.
Sandwell Area Child Protection Committee said it was a sad case but there was no way any agency involved in Christian's placement could have predicted what happened.
Committee chairman Dr David Low said it had been a long, thorough and exhaustive review.
"It's basic finding is that the tragic events leading to Christian's death could not have been foreseen," he said.
"It concludes that while more effective monitoring would have prompted an early review of the placement, there was nothing to indicate the events which led to Christian's admission to hospital could have been predicted."
Recommendations include a more active role for medical advisors in the adoption process and improved post-placement monitoring and support.
The review was concerned with adoption policies and procedures - not the circumstances surrounding Christian's death, the chairman added.
Mr and Mrs Gay are both hoping to appeal against their convictions and deny they force-fed the boy salt as a punishment for his behaviour.