A three-year-old boy was tortured and murdered by a couple employed to care for him after a string of failings by agencies monitoring his killers, a serious case review has found.
The report into the death of Ryan Lovell-Hancox made recommendations to a total of 14 different bodies after criticising Wolverhampton City Council, the Probation Service, a charity and police for errors made in the three years before the boy suffered a fatal brain injury.
Conducted by the Wolverhampton Safeguarding Children Board, the review concluded that Ryan was not protected during 2008 as separate agencies "failed to consider the wider picture".
Ryan died in hospital on Christmas Eve in 2008 after being attacked while being looked after by Christopher Taylor and Kayley Boleyn at her flat in Bilston, West Midlands.
The couple and the boy's mother, Amy Hancox - who knew nothing of the abuse - were all "well known" to the child protection authorities, the serious case review found.
But none of the agencies realised that Ryan was being cared for by Taylor and Boleyn, who were not flagged up as posing a risk to children because of poor record-keeping by the police and Probation Service.
Concluding that lessons could be learned from the tragedy, the report's author, Martin Burnett, identified a number of failings by several agencies, including a contractor providing Wolverhampton City Council's service for those leaving local authority care.
Several members of staff working for the contractor saw Taylor and Boleyn with Ryan during the course of December 2008, but the different sightings were not collated and no other agency was notified.
The report, which did not name those involved in the case, confirmed that a member of the contractor's staff saw a child presumed to be Ryan hidden underneath bedclothes at Boleyn's flat in Slim Avenue on the day he was fatally injured.
Speaking at a news conference in Wolverhampton, Mr Burnett said of the failings: "The police should have recorded child protection concerns in relation to (Boleyn) in September 2005, and in October 2005 the Probation Service should have recorded the assessed child protection risk posed by (Taylor) and they should have passed the information to Children's Services."
Mr Burnett added that the deficiencies in recording information did not directly cause the tragedy, but were significant in allowing Ryan to remain in his killers' care.
Mr Burnett added: "A number of failings have been identified which, taken together, help to explain how this came about.
"In relation to (Boleyn) and (Taylor) records were deficient and did not properly show the background level of risk posed by them."
The failure to keep proper records meant that when Taylor took Ryan with him to meet a probation officer in December 2008 "no alarm bells rang" and an opportunity to ask questions was missed.
The inquiry also established that the contractor providing Wolverhampton's leaving care service, which was monitoring Boleyn, failed to visit her often enough.
Mr Burnett noted: "If the contractor had visited (Boleyn) more frequently, it would have in all likelihood been clear that (Taylor) was living with her.
"It would probably also have become apparent that the child was living there too.
"The conclusion of the serious case review is that this child's death is a case from which lessons can be learned."
The case echoes that of Baby Peter, who died in August 2007 at the hands of his mother, her lover and their lodger.
The little boy, from Haringey, north London, had suffered 50 injuries despite receiving 60 visits from social workers, doctors and police over the final eight months of his life.
Taylor and Boleyn are both serving life sentences for Ryan's murder.
Their trial in March last year heard that Miss Hancox paid them £40 a week to look after her son, after realising she could not cope with the strains of motherhood.
The 21-year-old suffered from mental health problems and was trying to decorate her flat.
Miss Hancox and Boleyn were cousins, had grown up together, and Ryan's mother had no reason not to trust the 19-year-old when she left Ryan at the flat she shared with Taylor, 25, in November 2008.
The court heard how Ryan's life then turned to "hell" as he was forced to live in squalor during the month spent with Boleyn and Taylor.
The child was repeatedly beaten about the face, back and buttocks. His skull received 10 severe blows and he had more than 70 injuries to his body by the time he died.
Two days before his death, Miss Hancox confronted Boleyn and Taylor at their home as she tried to see her son.
But by this stage the boy had severe bruising to his face and they stopped her from entering the house.
Commenting on the findings of the serious case review, Sarah Norman, Wolverhampton City Council's strategic director for community, described Ryan's murder as a horrific and appalling tragedy.
Ms Norman said: "On behalf of the city council, I would like to express my deepest sympathies to his parents and their family for their unimaginable loss.
"I also want to say sorry to them for the things that we got wrong."
Although Ryan was not known to social services and was not classified as being at risk, the review found that the council's contract with the provider of its leaving care service was badly-drafted and self-contradictory in key areas.
The city council was also criticised for ineffective monitoring of the contractor by the serious case review, which found that the final contractor visit involved a staff member who had no social work qualification and insufficient training.
Mr Burnett stated: "One is driven to the conclusion that the contractor was giving this worker more responsibility than it was reasonable for someone in those circumstances to bear.
"Having seen the child at the flat, the worker took no action."
Admitting that the city council should have done more to help Ryan's mother, Ms Norman said: "We have learnt the lessons from this tragic case and have acted on all of the recommendations in the serious case review with the aim of minimising the risk of something like this happening again in our city.
"The serious case review has also highlighted the inadequate contract and monitoring arrangements we had with the charity Shaftesbury Young People, which provided our support service for young people leaving care.
"This service is now back in-house and run by the city council in order to work better with other care services."