The heartbreaking case of a mute, autistic boy who starved to death while clinging to his mother’s dead body could lead to a shake-up in how schools handle absences.

Four-year-old Chadrack Mbala Mulo was found with his arms wrapped around the decomposed body of Esther Eketi-Mulo in their flat on the Trelawney Estate, Paragon Road, on October 18, 2016. He is believed to have died 48 hours earlier, two weeks after his mother died of an epileptic fit.

Morningside Primary School staff tried to contact Esther on October 3 when Chadrack did not attend and paid a home visit two days later, but could not get past the security doors of the block. A week later they tried again, but again could not access the building.

It wasn’t until a cousin of Esther’s called police late on October 17 that officers forced entry into the flat and found the utterly tragic scene.

The school has changed its protocols to hold three contact numbers for each child, send staff to homes when they can’t reach someone by phone and call police immediately if they cannot get in.

Last year senior coroner Mary Hassell urged ministers to take action on the system schools use to deal with unexpected absences to avoid any more similar deaths.

Now the City and Hackney Safeguarding Children Board has published its serious case review into the deaths and made a host of recommendations.

The review found Department for Education (DfE) guidelines on how to deal with pupil absence was “weak” because it focused on getting them back into education, not their wellbeing. It said this was “likely to have been reflected in the actions of staff”.

One of 15 recommendations will see the chair Jim Gamble write to the DfE suggesting a stronger focus on safeguarding.

He said: “Chadrack’s death and the lessons set out in our review must become more than a terrible headline; they must map a route to a greater focus on the needs of the family and a response fundamentally driven by everyone thinking ‘safeguarding first’.”

He also recommended all schools hold three contacts for each child, as well as a professional contact.

Another aspect of the review was the security doors, which were a “clear barrier” to staff and shouldn’t have been. A recommendation was made that professionals should have a point of contact within councils’ housing services enabling them to get in.