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."
An unspecified number of employees, including some city council staff, have resigned or were sacked in the wake of the failings.
The man tasked with improving Birmingham's children's services, Peter Hay, described the latest case review as a "further blight upon this city's reputation".
Mr Hay, the city council's acting strategic director for children, young people and families, told reporters: "We have failed to meet the basic expectation that our children are safe.
"For this we are unequivocally sorry.
"We accept too that given our record in failing to improve children's services, our apology may ring hollow.
"We want today's report to be a point of real change in children's services.
"Our track record over recent years is poor and we do not flinch from acknowledging that a very different approach is needed."
Bridget Robb, chief executive of the British Association of Social Workers, claimed a "culture of failure" in Birmingham for many years seemed to have become ingrained.
Ms Robb said: "The council has an old-fashioned and hierarchical culture, where scapegoating has been the norm and staff are reluctant to admit when mistakes are made and when they are struggling.
"Birmingham children's services has had four management changes in four years and three department re-organisations. This constant instability is totally demoralising for social workers."
Calling for a change in the relationship between councillors, managers and frontline staff, Ms Robb said: "It is time for an honest appraisal of child protection provision in the city, across all agencies.
"We want to see a management culture where frontline staff are supported to improve rather than a 'witch-hunt' when things go wrong.
"This is not about excusing poor practice and covering up mistakes, but social workers do need to be empowered to express concerns about cases and say at the time what needs to change, if we are to better protect the city's children."
Four significant chances for intervention were missed, the report concluded, including three in the final weeks of Keanu's life.
As well as a hospital visit after the burn to the toddler's foot, a two-year developmental check and an appointment at an audiology clinic also took place in late 2010 and January 2011.
The head of the NSPCC, Peter Wanless, said: "Distressingly, as we found when the review into little Daniel Pelka's death was published, many of the lessons from this case have already come up time and time again in previous reports.
"We learn that a defenceless child was invisible, there was a lack of communication between agencies and that a manipulative parent was able to pull the wool over the eyes of professionals.
"It simply isn't good enough to say that lessons will be learnt from serious case reviews when all of the evidence before us suggests they are not."
Dr Hilary Emery, chief executive of the National Children's Bureau, said: "This case starkly demonstrates the unintended consequences of recent reforms to child protection - an overly bureaucratic process, lack of individual responsibility, increasingly complex organisational relationships and responsibilities, and no one advocating in the interests of the child."
Action for Children's head of safeguarding, Shaun Kelly, said: "Sadly, reports of children who have been murdered at the hands of people who are supposed to love and care for them are now all too familiar.
"And we hear the same lessons come up time and again - it is inexcusable that they are not being learnt."