Michelle Dickinson is serving a 16-year sentence
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Health services have been criticised following the death of a Cumbrian boy who was poisoned by his mother.
Michael Dickinson, seven, died in October 2000, after he was given anti-epilepsy drugs by his mother Michelle.
Dickinson, 32, of Seascale, is serving a 16-year sentence for child cruelty.
The report lists 34 recommendations to various agencies and says that Michael failed to receive co-ordinated care and the drugs were not properly monitored.
Dickinson was alleged to have duped doctors into prescribing medication for Michael after wrongly claiming he had epilepsy at the age of three.
Michael died from pneumonia in hospital in Leicester in October 2000, after spending 102 days on a life support machine.
The Serious Case Review into Michael's death by Cumbria's Child Protection Committee was published on Tuesday and says there was a lack of co-ordinated care and that Michael was a victim of fabricated or induced illness - a form of child abuse.
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Sadly the voice of the child is noticeably absent from this story
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It says a deterioration in Michael's condition was first noticed when he was less than 18 months old.
Aged five, his condition got so bad that teachers remarked he could no longer walk or talk.
The report says there was a failure to monitor his repeat prescriptions and he was given a cocktail of drugs that should not have been administered together.
Michael's perspective on what was happening in his family was never sought by the authorities.
Improved guidance
The recommendations call for improved communication between all health and social services professionals, training junior staff to voice their opinions freely to those in authority and monitoring repeat prescriptions and introducing alerts for suspect cases.
It also called for improved guidance on when it is permissible to hold meetings about a child in the absence of their parents, putting more emphasis on the child's rights over the duty to keep parents informed.
The report said: "Sadly the voice of the child is noticeably absent from this story."
Dr Bob Postlethwaite, chair of the Review Group, added: "I believe the result makes it clear that only one person was cruel to Michael - his mother.
"His form of abuse is complex and challenges professional norms. Agency responses could have been different, but even then the abuse to Michael probably would have still occurred."