17/09/2013 03:41 BST | Updated 16/11/2013 05:12 GMT

Daniel Pelka Could Have Been Given a New Life With New Parents - But People Failed to Trust Their Instincts

The brutal murder of little Daniel Pelka shocked our nation in a way that hasn't happened since the death of baby Peter Connelly over five years ago.

The details of his suffering in the weeks and months leading up to his death, and then the final blows that killed him, have shocked even our most experienced and hardened child protection experts. I felt sickened as I read through the finer points of this case such as Daniel taking hours and hours to die as he lay on a sodden and filthy mattress locked in a tiny bedroom.

Such a lovely boy that barely a photo exists of him without a big beaming smile on his face despite all the horrific things that were happening to him. Even though famished enough to gulp down offered titbits in seconds he still didn't forget his manners and managed to thank people in English - a language he was still struggling with.

Understandably, people have been saddened and outraged in equal measure. Many are questioning how something so awful has happened yet again? What really upsets me is so many good people would have given anything to provide that little boy with a fresh start, a new life with new parents. And a swift and decisive intervention at just the right time would mean he'd still be alive now, with a new family, running around like all little boys do. The only marks on his body being scrapes on his knees from playing football.

But that won't happen now.

Instead, today, we have the grim task of poring through a Serious Case Review (SCR) laying bare the failures that denied little Daniel this second chance. Before I talk about this I want to be absolutely clear on one thing: there are only two people ultimately responsible for Daniel's death and they are his mother and her partner. They are evil people who are now spending 30 years behind bars. Such cowards they even tried to blame each other in a pathetic attempt to escape justice. They showed no remorse and the judge rightly threw the book at them.

But sadly that doesn't remove the fact that chances to save him were missed, failings happened and a little boy literally began disappearing before people's eyes with little or nothing being done.

We can go over each recommendation and each failure with a fine tooth comb, and my team and I have done this and will continue to do so. But I've read this report more times than is probably good for my sense of outrage and I can tell you there's one clear lesson. And you don't have to be a child protection expert to understand it.

Too often we look for the complex, in-depth reasons why children are maltreated. But in many cases the blindingly obvious is staring us in the face. And in the case of Daniel Pelka it was almost impossible to miss. He was vanishing before our eyes as his weight plummeted dramatically, yet still no one took effective action. No one seemed able to save his life.

So, if anything positive is to come from this tragedy it must result in all of us seeing the child not the excuses. No amount of training or form filling or processes in the world can replace the fact that when a grown adult, especially one in a position of trust, sees parents violently attacking each other and drinking whole bottles of vodka at a time or sees a skinny child scavenging for food in a bin, alarm bells need to ring and action needs to be taken. It's simple common sense.

But people didn't trust their instincts. That voice in their head that said 'this isn't right, this boy is not OK' was ignored. Instead, many bought the lies and manipulation of his cunning and devious parents. Sometimes we don't want to believe parents can treat their children so appallingly, but sometimes they do. Professionals have to exercise healthy scepticism - if it looks as if a child is being abused, we expect action to be taken.

On top of the endless lies from his parents there were at least 27 reports or visits regarding their alcoholism and violent behaviour towards each other. But it seems no one really thought about the impact this behaviour had on the children, or they certainly didn't act on it, despite the fact that anyone working in child protection will tell you that substance abuse and violence in a home are two of the biggest warning signs for child abuse. Tragically, in Daniel's case, this failure to see and act at speed may have cost him his life.

Now is the time to say enough is enough. SCR's like this one have generated enough lessons now - we owe it to Daniel to ensure they are learnt, not filed and forgotten. Everyone must see the child, not the excuses. Everyone must assume it is their job to act and never assume someone else will. And to know that reporting is not an end in itself for people who work with children, but the first step to taking real action.

It's too late for little Daniel, but it's not too late for thousands of others.