A baby died of neglect at his mother's squalid flat despite repeated visits by social workers.
Officials called to check on nine-month- old Perrin Barlow a total of 47 times in 50 days because he was officially "at risk".
His mother Stephanie Horrocks was a known heroin addict who worked as a prostitute to pay for drugs.
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Stephanie Horrocks, 27, and her lover Mark McAndrew, 33. They were jailed for child cruelty following their son Perrin's death from bronchopneumonia, but Horrocks died of a stroke four days later
Neighbours reported seeing the "pasty" and "undernourished" faces of her two other young children pressed up against the window pleading to be let out, and said Perrin was so underweight he looked like a "doll".
Yet despite widespread concern about the family, the youngster was left to die of a chest infection brought on by malnutrition and dehydration.
Perrin suffered from malnourishment and dehydration before his death on July 16
Perrin's ordeal, described in harrowing detail at an inquest, is a chilling reminder of the Victoria Climbie tragedy.
After the eight-year-old African girl died seven years ago in Tottenham, North London, the resulting inquiry made damning references to a lack of communication between care agencies.
Yet no one intervened before it was too late for Perrin, who died from pneumonia brought on by woeful neglect seven days after the final social services visit.
On that occasion, social worker Catherine Capron visited the flat in Plymouth but found nothing wrong except that he was a little underweight.
She claimed his condition must have "deteriorated rapidly" after that.
The inquest heard that Perrin was allowed to stay with his mother even though she had a previous conviction for neglecting an older child. His natural father died in a car crash shortly after the boy was born.
Medical staff failed to tell social workers of evidence she was using drugs and police did not pass on information about her working as a prostitute. The child welfare agency Cafcas should have appointed a guardian to carry out an assessment but had such a backlog of work that it defied a court order to do so.
During the hearing, several neighbours spoke of their worries for Miss Horrocks's children, who were often left in the flat alone. When medical aid finally arrived for Perrin, a paramedic said the home was one of the dirtiest places he had seen in nine years of service.
After his death in July critical executive summary report by Plymouth's Area Child Protection Committee later described a "fundamental failure to protect the child from significant harm".
It said Perrin had been born "extremely vulnerable, premature with symptoms of drug withdrawal" but that the focus of care was on "the needs of the adults".
The report made 39 recommendations to social services, the police, doctors and other agencies.
It is understood no one was sacked or even disciplined after Perrin's death, although it is thought some staff were offered re-training. The three-day inquest at Plymouth Crown Court heard that neighbours became increasingly worried for Perrin after screaming, swearing and crying could be heard in the flat.
In January 2002, Perrin became increasingly ill from a chest infection and Horrocks was told to take him to hospital but refused claiming "she had other things to do".
Over the next six months Perrin's health deteriorated rapidly. Neighbour Janet Pay said: "Perrin always looked ill and lifeless. He looked like a doll. I contacted social services and the police on several occasions and got no reply."
Coroner Nigel Meadows recorded a verdict of natural causes "in which neglect contributed". He found that Perrin died because Horrocks and McAndrew ignored pleas from friends to take him to hospital when he became seriously ill.
They did not call an ambulance until he had stopped breathing by which time it was too late to revive him. Despite the repeated missed chances to rescue Perrin before he died in July 2002, Mr Meadows did not apportion any blame to social services. He said: "It seems that these days social workers, health visitors and those in the caring professions, when dealing with families like this, can be damned if they do and damned if they don't.
"If they take pre-emptive action and something goes wrong they can be open to public vilification but if they don't act and something untoward happens they suffer the same fate."
But he added: "Lessons have been learned from this case here and nationally and one always hopes this sort of case will never occur again."