Professionals failed to recognise "indicators of risk" concerning a toddler who was tortured before being killed by her stepfather, a report said today.
Daniel Bishop was jailed for 12 years after admitting child cruelty, manslaughter and wounding with intent to cause grievous bodily harm to two-year-old Lois in 2004.
During the sentencing in October last year, Cardiff Crown Court heard the 28-year-old from Caerphilly, South Wales, systematically abused, tortured and ultimately killed the toddler, leaving her with 13 fractures to various parts of her body, a cigarette burn, and crushing injuries to both her hands.
The court also heard Lois's 30-year-old mother, Sarah Bishop, turned a blind eye to the abuse. She was subsequently given six years' imprisonment after admitting child cruelty.
A serious case overview report has identified a number of mistakes made by child protection staff in the months leading up to the Lois's death.
The report's author, Peter Maddocks, said: "At the time of her death she had been identified as a child requiring the protection of all the agencies contributing to the child protection conference.
"This status of being a child in need of protection should have happened much more quickly.
"Some of this is attributable to information not being shared effectively at an earlier stage, but in the latter months it is a failure to recognise indicators of risk and to make properly organised enquiries and assessments.
"When the child protection procedures were invoked, further delays occurred. With the benefit of hindsight, if procedures had been followed, if Child 1 (Lois) had been the subject of properly organised supervision required of a detailed child protection plan, and if professionals had been less accepting of mother and had sought professional paediatric advice, different decisions may have been taken.
"Collectively, there was a failure to act with sufficient clarity of purpose."
Mr Maddocks also said Mr Bishop's antecedent history, littered with convictions for drug abuse and serious offences, were indicators he presented a risk of violence.
However, Mr Maddocks added: "There is nothing to indicate injury to a child in his previous history."
At a press conference today, Mr Maddocks said he was "very satisfied" by the response taken since the commission of his report.
David Hopkins, the chairman of the Caerphilly Safeguarding Children Board, said fundamental messages have been gleaned from the report which include recognising signs of hidden abuse, implementing robust risk assessment procedures and adhering to effective and efficient referral processes.
"This was a terrible tragedy and we all truly and deeply regret we were unable to protect Lois from the hands of Daniel Bishop," said Mr Hopkins.
He added: "The tragic loss of Lois's life highlights the challenges faced by a range of professionals dealing with extremely sensitive child protection cases every day. This case was complicated by the determined efforts of Sarah and Daniel Bishop to deceive professionals and cover up any signs of abuse or injuries to her."
Mr Hopkins said disciplinary action has not been against staff responsible for monitoring Lois's welfare.
A statement from the Caerphilly Safeguarding Children Board said: "This Serious Case Review is not about apportioning blame but about putting in place measures that will help improve all of the services involved in safeguarding children."
The statement added: "The review also concludes that, even had the enquiries been more purposeful and structured, the outcome may not have been different - that is we could not have predicted that Bishop would kill Lois."Reuse content