It is easy to play the blame game when a young life is lost in tragic and needless circumstances. And a number of national high profile cases over recent years have seen social workers bear the brunt of that blame.

But there can be no denying that in the case of Damian Clough, serious and significant mistakes were made. Autistic Damian was just 12 when he died, poisoned by fumes from a fire after he had been locked in his bedroom.

The Bradford Safeguarding Children Board has completed a Serious Case Review that leaves little doubt that Damian and his family were let down by those who should have been supporting them. The report speaks of a ‘wholesale failure’ among the professionals involved in the case to address the family's needs in an integrated way.

The priority must be to make sure similar failings do not occur in the future. But questions remain to be asked of those involved. Why was an unqualified worker allowed to supervise Damian’s case by senior managers?

Why were the needs of his family – in particular his sister, only 16 now, who cared for him because his mother worked nights – not more closely looked at? Why did the police not implement their child protection policies after visiting the home? Why was Damian rarely seen at home by social workers?

Damian’s father says he was ignored by social services when he tried to warn them what was happening. He believes a lack of resources and qualified people is at the heart of the problem.

Whatever the reason, we owe it to Damian’s memory to do all we can to protect children like him in the future – and to try to prevent another tragedy like this.