Three years after six-year-old Rikki Neave was found strangled near his home in Peterborough children are still at risk of "significant harm and neglect", according to a critical Social Services Inspectorate Report.
The men in charge of Cambridgeshire social services at the time of the failures have either retired or moved on to other top jobs and have not been punished. The report found that the department took more than two years to implement an action plan to address flaws in its child protection services - but those changes are already behind schedule.
The report, which criticises outdated procedures, serious shortcomings, and "unacceptably low-quality" services, places the blame squarely on management shoulders. However, only three frontline staff were disciplined. Four senior executives as the top of the management structure in place at the time have all left the council. The council stressed this was not connected to Rikki's death. But Brian Waller, acting Social Services director, said of their departure: "You can draw your own conclusions."
Rikki was found dead in a small copse near his home on the Welland Estate in late 1994. Last October his mother Ruth was found not guilty of killing him, but was jailed for seven years for cruelty. She had persistently asked social services to take him into care.
Earlier this year a report by the Bridge childcare consultancy found Rikki had been "failed" by social services, listing blunders over missing files, lack of communication and confusion as to whether Rikki was on the at-risk register.
The chief executive at the time, Gordon Lister, acknowledged that care had fallen "below acceptable levels". Last month, Mr Lister left the council and became chief executive of the Papworth Trust, a charity dedicated to helping people with physical disabilities.
Despite the criticism of his regime at Cambridgeshire - where he reportedly earned pounds 95,000 a year - he declined to comment yesterday.
When the SSI inspected Cambridgeshire in April and May this year, they found that progress was so "limited" that they concluded "Inspectors cannot yet provide sufficient reassurance... about the safety of children and young people from the risk of significant harm."
As a result, they recommended a further inspection be carried out next year.
Inspectors found that risks to children were not identified in a consistent way, and minutes of child protection conferences were "often provided too late to be of any value. The result was unfocused, passive work which was in some cases largely dictated by the parents to the possible detriment of their children's welfare."
Case recording was weak, and work was also limited by outdated procedures. Morale amongst front-line staff was low, and they did not consider managers were giving a clear sense of direction.
"Our report shows that, despite past statements by the council, serious and deep concerns remain about its ability to protect vulnerable children," said Sir Herbert Laming, the SSI's Chief Inspector.
In spite of the criticism, all of those at senior management level escaped without being disciplined. Three years ago Tad Kubisa was the pounds 65,000- a-year Director of Social Services before moving on to serve for a year as President of the Association of Directors of Social Services, advising government on social services in the UK. He retired from Cambridgeshire County Council at the end of last year and is understood to be semi-retired and living in Newmarket, Suffolk. He could not be contacted yesterday.
Ted Unsworth, 54, took over from Mr Kubisa at the beginning of the year and found himself in charge of an pounds 80m budget and a staff of 4,500. But he left the council several weeks ago after 20 years service to take up a salaried position as an adviser to the board of trustees of Turning Point, the drink and drugs rescue charity favoured by Diana, Princess of Wales.
A spokesman for the charity said he was not available yesterday. His new job, the spokesman said, was to develop a programme that would serve as a tribute to Diana's life.
At the time of Rikki's death, Matt Bukowski was group director for North Cambridgeshire. He has since left to become Director of Social Services in Lincolnshire. Mr Bukowski said: "I can't comment because I haven't seen a copy of the report."
Four others with responsibility for the case have left and three were suspended after Ruth Neave's court case, although they have since been reinstated.
Paul Boateng, the health minister, acknowledged the changing faces at the council and said: "Cambridgeshire failed to provide proper protection for children at risk of abuse or neglect. It is a legacy of incompetence at a senior level. Changes in senior management have opened up an opportunity for the council to act. I want a pledge that the council will accelerate its action plan."
Maurice Harvey, Rikki Neave's grandfather, welcomed the report saying he was glad it attacked the "generals not the troops".
The new chairman of the social services committee, John Holditch, said he accepted all the SSI's findings and that the council was "totally committed" to addressing weaknesses in management and practice.
the key failures
1 Children at risk of abuse not identified in a consistent way.
2 Work rarely based on a thorough written assessment of risk to the child.
3 "Unfocused passive work largely dictated by parents."
4 Case recordings weak and outdated procedures still in place.
5 Major shortcomings in assessments and care plans.
6. Action plan took two years before implementation.
7. Some groups developing guidance already behind schedule.
8 Many staff not aware of the action plan.
9 Low ratio of children's social workers led to high case loads.
10 Training opportunities limited because of workload pressure.