The Crown Prosecution Service dropped cruelty charges against the parents of Kim Griffin earlier this year, saying that it had insufficient evidence. Both Ann Griffin and George Hadjouannou had exercised their right to silence and refused to make statements to the police.
Yesterday, Dr Harold Price recorded a verdict of unlawful killing after being told that Kim was rushed to Newham General Hospital, east London, last September with multiple injuries that could not have been caused by accident.
Dr Price said: 'The public are very disquieted that no charges have been brought. I understand that a Royal Commission on the criminal justice system is to report in June this year and it is possible that the right to silence may be one of the subjects (it will address).
'Perhaps in the continental inquisitorial system, this matter might have been brought to court at least, as the rules of evidence are not so strictly adhered to as here.'
The case has already provoked debate among lawyers, with some senior barristers arguing that abolition of the right to silence would have made little practical difference to the chances to bringing a prosecution over Kim's death. The issue is a red herring, they say.
Yesterday, Dr Peter Vanezis, head of Forensic Medicine at Charing Cross Hospital, west London, told Dr Price that Kim's injuries were consistent with her being swung, pulled and violently shaken.
Mr Hadjouannou, who had been ordered to attend the inquest along with Ms Griffin, listened impassively as Dr Vanezis said: 'The child may have been propelled or swung on to a hard surface.
'The broken ribs are compatible a grabbing of the child by the chest and being squeezed and shaken around. The arm was pulled, possibly with a twisting motion.'
The coroner criticised doctors who had seen Kim in the weeks before she died, saying that they 'may have made a more urgent referral to the social services and the child protection team'.
Deborah Sher, a health visitor, said there had been a series of complaints about Kim's condition, including claims that she had been scalded and had a red mark in her mouth. But she initially decided against referring the case to Tower Hamlets social services as the doctors who had examined Kim, Alison Arnott and Jonathon Bernstein of the Royal London Hospital, believed the injuries were not deliberate.
But on 4 September, Ms Sher was told that Mr Hadjouannou had another child in care, prompting her to refer Kim to social workers. Even so, this procedure was only completed on 7 September, the day before Kim was admitted to hospital.
Neither Mr Hadjouannou nor Ms Griffin answered any questions in the witness box, their lawyers telling the court that they had been advised not to do so.