A mute and autistic four-year-old boy starved to death whilst clinging to his mother's dead body in east London after being left with her corpse for up to two weeks.
Chadrack Mbala Mulo was found dead on 20 October 2016 with his arms wrapped around the partly decomposed body of his mother after she died suddenly.
Esther Eketi-Mulo, 35, is believed to have died after an epileptic fit on either 1 or 2 October with Chadrack dying of malnutrition and dehydration and autism spectrum disorder on 18 October, according to a report into his death.
It is believed that Chadrack, from the Trelawney Estate in Hackney, was unable to raise the alarm and neighbours said that they thought the smell was coming from her cooking, reported the Hackney Gazette.
A Prevention of Future Deaths report being sent to the Minister of State for Vulnerable Children and Families says Chadrack was not seen in school after 30 September.
One neighbour told the Gazette: "It has haunted me for a long time, that I could have helped, and I didn't know.
"I keep thinking to myself: 'Did I hear him? Did I hear him next door?' But he never spoke. Never. He just hid behind his mum and held onto her clothes.
"He couldn't even call out or speak through the letterbox."
The report added that staff at Morningside Primary School where he attended were concerned and rang his mother on several occasions. They even visited the home twice, but could not gain access to the block of flats.
Coroner Mary Hassel said in her report: "The likelihood is that Chadrack lived alone in the family home for over a fortnight after his mother's death.
"He was found a couple of days after his own death, with his arms around her body. She was by then very decomposed."
The inquest raised questions over procedures with Hassell urging that a new system to handle unexplained absences from school.
These include that each school must have a telephone number of three different adults concerning each child and that if the adults cannot be contacted, schools must immediately send a member of staff to the family home. If this does not work, staff must call police.
Hassel wrote: "This protocol seems very sensible, but is clearly driven by the appalling tragedy of Chadrack's death. It seems unlikely that other schools in Hackney, elsewhere in London, or indeed in the rest of England and Wales, have such a system in place."
Janet Taylor, Chadrack's headteacher said the school had followed its procedure for checking on children missing from school.
"Chadrack's tragic death has devastated all those who knew him at our school," she said according to Schools Week. "We will remember him as a happy little boy and the circumstances of his death are heartbreaking."
Minister of State for vulnerable children and families Edward Timpson must respond to the Coroner's report by 19 June.