An inquiry published today into the death of baby Jessica Randall has concluded that her death could have been avoided.
The 53-day-old baby from Northamptonshire was murdered by her father Andrew Randall in November 2005 after he sexually abused her. He was convicted of her murder at Northampton Crown Court and jailed for life on 13 March 2007.
The report was published by the Local Safeguarding Children Board for Northamptonshire - a board made up of medical officers, council workers and police.
According to the report, as early as 12 October 2005 there were grounds for a referral to Children and Young People's Service (CYPC) due to her mother's previous history of mental health problems.
However, the report also recognised that Mr Randall did not have a criminal record and there was nothing in his medical records to suggest he was a danger to Jessica.
In its conclusions it stated: "At no stage was Jessica Randall recognised as a child at risk and in need of protection. Consequently, those procedures which were designed to protect Jessica Randall were never activated.
"In recognising that opportunities had been missed to identify signs of abuse we must conclude that the outcome for Jessica Randall may have been different had these signs been acted on, as this would have created opportunities for assessment and involvement of other agencies by activating protective procedures."
The report identified a number of failings in Jessica's care and treatment by Kettering General Hospital NHS Trust (KGH), Northamptonshire Teaching Primary Care Trust (NTPCT) and the Children and Young People's Service (CYPS), managed by Northamptonshire County Council.
Commenting on the review on behalf of all three agencies John Parkes, Chief Executive for Northamptonshire Teaching Primary Care Trust, said:
"We accept that there were failings by the agencies and our top priority is to make sure that the interests of the child are made absolutely central to everything we do."
"All of the three organisations involved have welcomed the LSCBN review and have co-operated fully with it. We have worked very closely together to address all of its recommendations."