A TRAGIC teenager who was found hanged grew up amid a background of violence and drugs — but professionals failed to notice the risks he was exposed to on a “daily basis”.

The findings of a Serious Case Review into the death of 15-year-old Jake Dunstan have been published by Bolton Safeguarding Children Board and they and children’s services bosses have called for a greater understanding of the impact a troubled home life can have on a child.

Education bosses have accepted that there “are important lessons to be learned” following the inquiry.

MORE: Jake Dunstan death: Education chiefs on 'lessons to be learned' from tragic case of teen who hadn't been to school in 2 years

Jake was found by his father hanging in February of last year. He had not been at school for almost two years.

The review found that focus on his lack of school attendance left agencies addressing just one area of Jake’s life when in fact his psychological, emotional and mental health needs were of greater concern.

Children’s services and police had been involved in Jake’s life from a young age, after concerns about neglect and allegations of family violence and parental drug dealing — and later his absences from school.

Jake is identified in the report as SB and his mother as MSB.

The Serious Case Review Team stated: “The family’s social history and known parental substance misuse should have alerted professional to his vulnerability and the risks to which SB, as a child, was exposed on a daily basis."

Instead it was assumed because of his general demeanour and no sign of behavioural difficulties, that Jake was coping with his home environment and parents’ lifestyle — and the focus was on getting him back to school.

The review painted a troubled picture of Jake’s upbringing with police being called on several occasions in response to calls about violence within the home, where extended family also lived.

There were a number of occasions when police were called to the property in response to violent incidents — in relation to fighting between male adults which sometimes involved Jake — including a domestic violence incident, and no further action was taken by Bolton Children’s Social Care team after it was referred to them.

In 2011 police were called out in response to “serious concerns” about violence in the home when Jake was present.

In the case of alleged assaults on Jake — who also made a call — no police action was taken as Jake said no assaults taken place

Three referrals about lack of parental supervision and parental substance misuse were recorded as “being for information only” or considered as “malicious unsubstantiated concerns” and did not lead to involvement by the social care team.

Jake, described as a well-mannered child, was made subject of a ‘child in need plan’ in 2007 after school attendance did not improve and was put on a ‘child protection plan’ in summer 2008 under the category of neglect.

The Serious Case Review found: “Records refer to concerns about SB’s poor school attendance, concerns about home conditions, missed health appointments and MSB being on bail, charged with supplying heroin.”

A decision was made to pursue care proceedings when the parents failed to engage, but did not go any further.

Despite concerns about the family’s hostility to help, concerns about Jake were “stepped down” from child protection to child in need status.

In February, 2011 the family moved to live with extended family in Blackburn with Darwen, where Jake’s attendance improved. The move was seen as a fresh start, and both parents told services they had been drug-free for some time.

Jake’s attendance started to drop in the summer of 2011 and the family moved back to Bolton in 2012.

According to records Jake attended school for the last time in February, 2013 despite intervention from the school —including more than a dozen visits in one day and bringing schoolwork to his home — intervention from agencies and threats of fines.

Jake died a week after his mother was arrested and taken to court over Jake’s school attendance, where she was issued with a fine.

The review concluded: “The death of a young person is always tragic and especially so when death occurs because of their own actions. This review has highlighted a number of shortcomings in practice, which contain important lessons for agencies although it cannot be said they would have prevented the death of SB. Two broad themes emerge; the need for improved understanding by professionals of the impact on children, including adolescents, of the co-morbidity of domestic violence and substance misuse; and the challenge of working with resistant and hostile parents.”

It added: “The Review Team concluded that whilst there were no obvious or outward indicators of SB’s vulnerability and intentions, professionals were totally unaware of what life felt like for this young boy.

“SB did not want to see or engage with professionals and most of what was known about the child was actually told by MSB. However, SB’s lack of engagement with agencies should have heightened professional realisation of risk. Professionals viewed SB as a very likeable young person and although they wanted to get him back into school, this became their sole purpose in trying to engage with him and consequently and perhaps inevitably, he became lost to the very systems designed to secure his his welfare and keep him safe.”

The review team found that there was a failure to work within a multi-agency context, meaning key information was not shared or discussed, leaving professionals working in isolation.

Six recommendations were made including developing skills of professionals in working with hostile parents and resistant adolescents and gaining knowledge about the impact of long-term neglect on adolescents and the associated risks.

And to ensure there are systems in place to share information and more effective ways to work with families professionals are “stuck”.