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A seven-year-old girl starved to death in Birmingham after a catalogue of "missed opportunities" by social services and other professionals, according to a serious case review.
The report, by the Birmingham Safeguarding Children Board (BSCB), comes more than two years after Khyra Ishaq died at her home in Handsworth.
Following months of starvation and cruelty at the hands of her mother and stepfather, Khyra died in May 2008 when her body succumbed to an infection.
But the report, published in full on Tuesday 27th July, found that her death could have been prevented, and occurred after the authorities "lost sight" of her.
Hilary Thompson, chairwoman of the BSCB, said: "The serious case review concludes that although the scale of the abuse inflicted would have been hard to predict, Khyra's death was preventable.
"The report identifies missed opportunities, highlighting that better assessment and information-sharing by key organisations could have resulted in a different outcome."
The 180-page report found that, despite concerns being raised by members of the public and school staff about Khyra's welfare as far back as March 2006, information was not acted upon and safeguarding procedures were not properly followed.
It said: "There were a number of early missed opportunities for intervention by professionals.
"Three incidents during March 2006 were not progressed, either by failures of paperwork to reach the correct departments, failure to follow safeguarding procedures, or to conduct thorough checks prior to case closure, resulting in any knowledge and intervention remaining purely single agency at that stage."
The review, which began in May 2008, concluded: "Had there been better assessments and effective inter-agency communication over a period of time it (Khyra's death) could have been prevented."
A complaint of harrassment by Khyra's mother, Angela Gordon, against a social worker who visited their Handsworth home in February 2008 "generated a reluctance" to complete an assessment, the report found.
It said: "The complaint by the mother... appeared to impact upon the Children's Social Care manager and practitioner.
"This action appears to have generated a reluctance to follow through on plans with a partner agency to effectively pursue assessment procedures, for fear of wider repercussions within the complaints process."
The report continued: "Whilst a number of agencies and individuals sought to deliver effective services to the child... there were others who lost sight of the child and focused instead upon the rights of the adults, the adults' behaviours and the potential impact for themselves as professionals."
In March, Mr Justice Roderick Evans sentenced Khyra's mother Angela Gordon, 35, to 15 years and jailed her former partner, Junaid Abuhamza, 31, indefinitely for the public's protection, with a minimum term of seven-and-a-half years.
The pair were cleared of murder during a trial at Birmingham Crown Court but convicted of manslaughter.
During the trial it emerged that Khyra had been removed from school in December 2007 and subjected to a punishment regime which included standing outside in the cold for long periods, having cold water poured over her and being beaten with a bamboo cane.
She and five other children in the care of Gordon and Abuhamza at their Handsworth home were deprived of food and prevented from entering the fully-stocked kitchen by a bolt fixed out of their reach on the door.