Four-year-old Daniel Pelka's doctors, school staff and social workers missed countless opportunities to save him from the intolerable abuse at the hands of his mother and stepfather, but the boy remained "invisible", a review has found.
Chance after chance was missed to intervene in the case of the tragic four-year-old boy, who was beaten to death by mother Magdelena Luczak and brutal former soldier Mariusz Krezolek.
A serious case review into the death of Daniel Pelka found repeated failures by the agencies set up to safeguard children's welfare but concluded nobody could have predicted his death at the hands of an abusive mother and stepfather last year.
His mother and stepfather "misled and deceived" a host of child protection agencies by spinning a "web of lies" to conceal systematic abuse of the boy.
Daniel, from Coventry, died of a head injury on March 3, 2012.
The report's author, Ron Lock, said: "No one professional, with what they knew of Daniel's circumstances, suspected or could have predicted that he would be killed.
"This was a complex and tragic case.
"Daniel's mother seemed plausible in her concerns about him, and no concerns were expressed by neighbours or the wider community.
"Strong concerns nevertheless emerged about Daniel's circumstances and his care, although at no point were practitioners who had contact with him, prepared to think the unthinkable and consider that he might be suffering abuse.
"But if professionals had used more enquiring minds, and been more focused in their intentions to address concerns, it's likely that Daniel would have been better protected from the people who killed him."
The report also revealed for the first time, through 27 separate police logs recorded between 2006 and 2011, how Daniel grew up in a household dominated by routine domestic violence and alcohol abuse.
Luczak and Krezolek, both originally from Poland, were convicted of the youngster's murder following a trial earlier this year and are now each serving a minimum of 30 years behind bars.
During their trial at Birmingham Crown Court, the jury heard how Daniel had been kept locked in a box room as a virtual prisoner, fed salt, and routinely beaten - at one point his mother held his head under water in the bath.
The serious case review concluded several critical opportunities were missed to intervene in Daniel's care.
There was too much reliance in accepting Luczak and Krezolek's version of events, with the report concluding health professionals and social workers could instead have dared to "think the unthinkable".
The review by Coventry Safeguarding Children Board has published 15 recommendations aimed at preventing such a failure happening again,
These include calls for greater communication and co-ordination between the different child protection agencies, and a strengthening of working procedures and staff training.
Children and Families Minister Edward Timpson has now written to the board asking for further analysis of why the failures happened.
"The fact that, according to the report, there is 'no record of any conversation held with him by any professional about his home life, his experiences outside of school, his wishes and feelings and of his relationships with his siblings, mother and her male partners' speaks volumes."
Published in the report for the first time are West Midlands Police logs, revealing Luczak had three consecutive partners who were abusive to her, and charting how officers would be called to the family home to find one or other of the adults drunk.
In one incident in 2008, Luczak, 27, was reported as being in the street having taken an overdose "because her partner had left her", although no reference was made to Daniel who would have been six months old at the time.
In another in May 2010, officers arrested Krezolek on suspicion of assault at home after Luczak claimed he had slammed her finger in the door, with police recording that Daniel was at home at the time.
Officers responding to a call to the family home involving a knife in August that year, reported that Luczak was claiming Krezolek, 34, had attempted to strangle her, while in December 2010 a neighbour called to say Luczak had "locked children in the house" and there was "lots of screaming and shouting".
On that occasion, no checks were made on the children although the matter was referred to the police's public protection unit.
The safeguarding children board said there was "inconsistency" in when referrals were made by the police and how they were dealt with.
The review also looked at several missed opportunities by child welfare agencies to intervene on Daniel's behalf, including in January 2011, when he was brought in to accident and emergency with a broken arm caused, his mother and stepfather falsely claimed, when he jumped off a sofa at home.
A doctor did refer the issue to social services, who then carried out an assessment, but a follow-up was deemed unnecessary.
The safeguarding children board reflected that at no point was Daniel spoken to on his own by social services about his home life.
Geoffrey Robinson, MP for Coventry North West, said "clearer lines of responsibility" need to be drawn in child protection cases.
He told Daybreak: "The problem is systems are too complex and cumbersome.
"What the system is lacking is clear lines of responsibility and accountability. What department has the main responsibility."
Amy Weir, chairman of the Coventry Safeguarding Children Board, said that she "accepted" a clearer understanding of who is responsible for a child had to be established.
She added that the death of Pelka had "severely affected" those involved in the case.
The review also pointed to the last six months of Daniel's life when there were "a number of missed or delayed opportunities to intervene more effectively to assess and respond to the mounting concerns about Daniel's behaviours, physical injuries, lack of growth and weight loss".
At Little Heath Primary School in Coventry, teaching staff noticed Daniel was "wasting away" and had been caught stealing food from other children's lunchboxes or stealing scraps from the bins - but his behaviour was put down to a medical condition rather than child abuse.
However, the report noted there was a general "lack or urgency" by most health professionals to have any such issues attended to by a paediatrician, doctor or school nurse - not helped by Luczak's "deception" as the caring mother.
The serious case review report read: "The significance of his condition and of his deterioration was not as evident to the health workers, and school staff did not collectively and purposefully generate their concerns into a coherent child protection referral."
The report did add there were efforts made by the school to inject urgency into Daniel's case, with the school nursing support worker highlighting her concerns when Luczak cancelled the second of two paediatric appointments, and the deputy headteacher "taking the unusual step" in January 2012 of calling his GP.
However, the GP's recommendation was to ask Luczak to make an appointment, while the case review team reflected a more "pro-active" position should have been taken.
The report also noted an appointment with the community paediatrician in February 10, less than a month before Daniel's death, was "a key opportunity" to intervene, but again the signs of emotional and physical abuse were missed.
The case review's authors also noted their "concern" that when Daniel turned up to school with injuries, these were not properly recorded, concluding it was "apparent the school did not have clear protocols".
"With the background of mounting concerns by the school about Daniel's obsession to seek out food, as well as poor growth and possible loss of weight, it was surprising and very concerning that these injuries were not linked to those concerns."
Concluding the report, the safeguarding children board stated too often concerns about the boy's health had been "viewed in isolation".
Addressing the question of whether Daniel's death could have been preventable, the board said: "It could be argued that had a much more enquiring mind been employed by professionals about Daniel's care, and they were more focused and determined in their intentions to address those concerns, this would likely have offered greater protection for Daniel."
Coventry City Council chief executive Martin Reeves said: "Daniel was murdered by the two people who should have loved and protected him most, but all organisations in Coventry involved in Daniel's short life now have to face up to their responsibilities and the part they played in the missed opportunities that could have protected Daniel.
"We are sorry we did not do enough to protect Daniel.
"The report makes clear that the sharing of information and communications between all agencies was not robust enough and no-one fitted together the jigsaw of what was really happening to Daniel."
Reeves said the council had already improved working practices and training for its social workers and staff in schools.
Assistant Chief Constable Garry Forsyth, of West Midlands Police, said the force had improved its safeguarding children processes and information-sharing with partner agencies and accepted there needed to be "a more holistic approach when dealing with multiple incidents involving domestic abuse, in particular where children reside".
Russell Hobby, general secretary of the National Association of Head Teachers, said: "NAHT firmly believes that the leaders and staff of Little Heath acted properly on the information available and within the limits of the powers they had been given. It is extremely important to remember that no amount of vigilance by a school can compensate for the wilful misdirection of a deceptive and manipulative individual. Daniel was murdered by his mother and her partner, not by his school."
But the British Association of Social Workers (BASW) questioned the effectiveness of serious case reviews, expressing concern that the findings are not properly shared with child protection social workers.
Research carried out by the BASW found one quarter of its members never get the chance to read serious case review reports when they are published.
It found 67% of the 238 social workers questioned said they "only sometimes" get to read the recommendations from reports, and 17% never do.
Meanwhile 97% said they would like to see an online database of all reviews for them to access easily.
BASW Chief Executive Bridget Robb said she would like to see better use of serious case reviews as a learning opportunity for all professionals tasked with protecting children.
"We can understand the public perception that when serious case reviews are published there is a surge of publicity but then nothing much seems to be done with the findings," she said.
"Serious case reviews focus on what was unique in each case. If they are to be used for professional learning, we also need them to identify a few key messages for everyone. This is not straightforward to do, but essential if they are to have wider use.
"Rather than the current ad hoc distribution of SCRs, where hard pressed staff are expected to read and interpret findings on their own and in their own time, we'd like to see structured briefing podcasts for professionals produced by the authors of the SCRs so that professionals can hear the common messages, and where possible opportunities for professionals from a range of disciplines to come together to discuss the key messages and also to share good practice."