The Ombudsman, Bruce Barbour, today releases a report of his findings into the two-year-old's death at Rosemeadow.

He found that neither agency effectively protected the toddler before he was murdered on October 11, 2007. His body was found in a suitcase, floating in a duck pond at Ambarvale, a week later.

Dean's mother, Rachel Pfitzner, was yesterday sentenced to a maximum 25½ years in jail after pleading guilty to murdering her boy.

Dean had been cared for by his paternal grandmother, Ann Coffey, until Pfitzner failed to return him following an access visit in July 2007.

Ms Coffey was taking court action to recover Dean; Pfitzner asphyxiated him on the same day a court ordered that he be returned to Ms Coffey's care.

“My investigation found that the actions taken by both agencies did not effectively protect Dean," Mr Barbour said.

"DOCS received numerous risk of harm reports about Dean and his [family] in the year before he died, none of which received comprehensive assessment.

"The non-government family support service worked with Dean and his mother at a critical time. However, the service failed to effectively identify the risks to Dean, and to convey accurate information about the family's situation.”

Documents tendered to Pfitzner's Supreme Court sentencing hearing reveal that in the weeks before Dean's murder, she told a non-government family support service that she was not coping and "wanted him gone as soon as possible".

His death was one of several that prompted a special inquiry into child protection services by retired judge James Wood.

Mr Barbour said the Government's Keep them Safe action plan, drawing on the inquiry's recommendations, "is an attempt to reform the system and address the types of problems identified in this report”.

However, he said it was essential to strengthen the sector's capacity to identify correctly, and respond to, serious child protection cases.