A two-year-old boy who was beaten to death by his mother became "invisible" to the authorities while being subjected to months of cruelty, a damning report has found.
A serious case review into the murder of Keanu Williams concluded that professionals involved in his care failed to meet even basic standards of good practice.
The independent report, published today by Birmingham Safeguarding Children Board, said child protection workers in various agencies "collectively failed" to prevent Keanu's death.
Keanu, who was born in Torbay, died in Birmingham in January 2011 after suffering a skull fracture and a severe abdominal injury at the hands of Rebecca Shuttleworth.
Shuttleworth, formerly of Hay Mills, Birmingham, was jailed for life in June after a near-six-month trial heard her son suffered at least 37 injuries.
Making eight recommendations to the organisations involved in Keanu's care, the review's author said various agencies were guilty of a "loss of focus" after a core assessment made shortly before the toddler's first birthday.
The report stated: "The main finding of the review overview report was that professionals in the various agencies involved ... collectively failed to prevent Keanu's death as they missed a significant number of opportunities to intervene and take action.
"They did not meet the standards of basic good practice when they should have reported their concerns, shared and analysed information and followed established procedures.
"The serious case review panel was in agreement that Keanu's death could not have been predicted.
"However, in view of the background history of Rebecca Shuttleworth... it could have been predicted that Keanu was likely to suffer significant harm and should have been subject of a child protection plan on at least two occasions to address issues of neglect and physical harm."
Excuses given to health professionals by Shuttleworth after incidents of abuse, including a radiator burn to his foot, were not credible, the review found.
The 182-page report said: "Keanu experienced a number of presentations to hospital and to the GP, which were all explained by Shuttleworth as bumps and falls due to unsteadiness.
"The last hospital presentation involved a child protection medical assessment which was not undertaken in accordance with good practice standards.
"Keanu was returned to Shuttleworth's care with a burn to his foot believed to have been caused accidentally by a hot radiator.
"Based on the medical evidence, this conclusion was mistaken and therefore Shuttleworth's description on the 'accident' was not deemed credible."
The report follows other highly critical serious case reviews into child deaths, including the murder and starvation of Coventry four-year-old Daniel Pelka.
Noting similarities with other case reviews conducted in the West Midlands, the report into Keanu's death added: "The standards of practice revealed when some frontline professionals and managers were undertaking basic child protection tasks were of serious concern as several opportunities to protect Keanu were missed.
"The core business of the Birmingham Safeguarding Children Board was characterised by inattention to procedures and protocols and an absence of reasonable judgment when making decisions about Keanu in a number of instances.
"From this it follows that the core business of the Birmingham Safeguarding Children Board was not functioning well enough to ensure effective multi-agency practice in meeting Keanu's needs."
Nursery staff were also criticised in the report for not alerting social services after seeing a number of marks on bruises on Keanu's body when he appeared distressed four days before his death.
"No referral was made and clear guidelines and procedures were not followed as staff believed the explanations put forward by Shuttleworth," the report noted.
Addressing mistakes identified in other previous reviews, the report went on: "A number of the issues which have arisen are familiar themes nationally, such as poor communication between and within agencies, a lack of analysis of information, as well as a lack of 'professional curiosity'."
A lack of confidence among professionals in challenging parents and shortcomings in recording systems were also highlighted by the review.
Responding to the report, the independent chair of Birmingham Safeguarding Children Board, Jane Held, expressed "very deep regret" on behalf of all the agencies involved.
Speaking at Birmingham's Council House, Ms Held said: "We apologise unequivocally for what were totally unacceptable and unnecessary failures, both collectively and individually, in every organisation which had contact with Keanu."
Fully accepting the report's recommendations, Ms Held added: "Keanu died because there was a failure across every agency to see, hear and respond to him in the context of what he was experiencing at any one point in time.
"No one walked in his shoes.
"Staff were distracted by his mother's needs and by taking what she was telling them at face value."