NSW Community Services (CS) caseworkers couldn't step in and intervene after red flags were raised, because of a lack of staff, a NSW deputy state coroner has found.
The inquest into the death of the child from the NSW Hunter region exposed breakdowns in communication between government agencies that failed the young boy.
NSW Deputy State Coroner Elaine Truscott has recommended health policy be changed so that child protection issues are properly identified.
Mr Truscott has also recommended the John Hunter Children's Hospital consider establishing a weight management unit to treat children with serious obesity and other eating disorders.
According to her findings delivered on Friday, the child, who cannot be identified, suffered a cardiac arrest in September 2010.
He had been in hospital two years earlier when, aged eight, he was diagnosed with morbid obesity and sleep apnoea.
The child was given a ventilation machine to help him sleep and his parents were warned in 2009 his condition was life-threatening.
But a doctor later told the inquest the child's parents didn't think he was overweight, let alone obese.
The child weighed 50 kilograms and was 130cm tall when he was eight years old and the problem worsened in the following two years.
Medical staff noted the child's parents would feed him high calorie food when he was hospitalised despite advice to stop.
In March 2009, a doctor notified community services that the child was at risk of harm after the family continued to miss appointments.
Community Services received another risk of harm report in 2010.
The inquest heard on the night the child suffered a heart attack, his parents had gone out to get him takeaway food.
The findings explain the child's parents had battled with drug abuse and had been on methadone for years.
The parents, through a lawyer, said they loved and cared for their son, who was the youngest of six.
But Ms Truscott said parenting a sick child required more than that.
"It requires commitment, and a capacity to accept inconvenience and change," she said.
Ms Truscott found the circumstances of the child's death involved his parents not attending medical appointments and not following through with weight-loss requirements.
"They failed to identify that he was in an extreme life-threatening state, even when they made the decision to take him to hospital," she said.
Ms Truscott found a breakdown in communication between community services and health staff contributed to an intervention in the child's case not occurring.
And even when high risks of harm were identified, a lack of caseworker numbers meant intervention was not available, she stated.
Ms Truscott said the lack of intervention may still happen despite the massive overhaul of the system in 2010.
"My recommendations do not address the obvious necessity for more funding to employ more CS caseworkers, to meet the needs of more children who are at significant or even high risk of harm," she said.
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