The panel charged with investigating the untimely death of children found that the Department of Children and Families failed to intervene and make sure a mother was receiving services before the death of a 2-year-old child.

According to a report by the Office of the Child Advocate with support and assistance from the state’s Child Fatality Review Panel, Londyn Sack, whose mother is facing manslaughter charges, died from ingesting Suboxone — a drug used to treat adults who are addicted to or dependent on opioid drugs.

The report found that the family was subject to multiple child welfare reports between 2007 and 2014 and new concerns were reported to DCF when Londyn’s baby brother was born. However, the agency did not request the family’s North Carolina welfare records until after Londyn’s death.

The 9-month investigation found the family moved back to Connecticut in 2013 shortly after the death of Londyn’s step-grandfather in the family home in North Carolina. He had just been released from jail and he died the following day, according to records from North Carolina.

Five months after returning to Connecticut, DCF received a call from the community hospital to report concerns about the mother’s mental health.

“The reporter indicated mother was feeling overwhelmed and considering adoption after giving birth to her fourth child, born less than a year after Londyn’s birth,” according to the panel’s report. “The reporter noted that Londyn’s mother presented with a history of self-injury and diagnoses of Anxiety, Depression, and Borderline Personality Disorder. Mother also had attempted suicide on multiple occasions, including during this pregnancy and she reported a history of Post-Partum Depression.”

But the mother did not follow through and seek the mental health treatment the hospital recommended. After considering the adoption process, the mother decided to keep the child.

The mother was referred to a community partner for services for her and the children and attended the assessment, but missed 9 out of 20 case management meetings. Two months after the case was closed, Naugatuck Police were called because Londyn, then age 22 months, was in a diaper near the edge of Route 6 in the snow.

Londyn’s mother was in Bristol buying a coat she found on Facebook and she left Londyn with her 13-year-old sister and 19 year-old uncle. The case was accepted for investigation by DCF, but the allegation of physical neglect was not substantiated and DCF closed the case at the investigation level; no services were noted.

Seven months later, Londyn’s mother was arrested for shoplifting. A month after that, the Plymouth Police Department reported an anonymous call from a friend of Londyn’s mother asserting concern for the physical safety of Londyn and other children in the home.

According to the report, the anonymous caller reported to police that the mother stated, “I beat the shit out of them; I don’t know what I did to them,” referring to her two youngest children (Londyn and her 1 year-old brother). Police reported to DCF that an officer conducted a child well-being check and saw bruises on Londyn’s face as she slept. Police reported that the family, including Londyn’s siblings, denied abuse and claimed that the child is rambunctious and had fallen.

Because the allegation was not accepted for investigation, DCF did not request or facilitate an examination of the child by a medical provider to corroborate the mother’s history for the mechanism of the bruises or look for other signs of abuse, and DCF did not seek to identify or interview the person who made the abuse allegations to police.

That call was made on September 28, 2014. DCF closed the case file it had on the family on Oct. 6, 2014, and Londyn died Oct. 19, 2014.

The report concluded that “DCF did not obtain adequate information regarding the mother’s mental health status, substance abuse history or the impact of these issues on the children until after Londyn died.”

Twice the family was classified as low risk by DCF and the agency was contacted five times in the 19 months before Londyn’s death.

DCF told the panel and the Office of the Child Advocate that it has taken concrete steps to improve its response following Londyn’s death. Those action steps include changes in leadership in that region of the state, increased collaboration with community partners, drafting new infant and toddler protocols, and developing better risk assessment tools.

“Such tragedies are rare among the tens of thousands of families and cases we serve, but nevertheless we are always working to prevent these types of heartbreaking events from occurring again,” DCF said in a statement Tuesday. “Despite being an isolated case, we hold ourselves to the highest standards. We believe that we can always learn and improve by carefully reviewing our work.”