James Larkin was found guilty of the manslaughter of his partner’s three-month-old baby at Sheffield Crown Court earlier this week.
But now, a serious case review published by Doncaster Safeguarding Children Board has revealed official agencies failed to share information which may have given them a better chance of protecting the youngster, referred to as Child A in the report.
The review found that there was a lack of information sharing across adult services and an assessment of risk should have taken place.
The author of the report said: “Had this taken place it may have resulted in an earlier referral to children’s social care. This would have ensured an improved understanding of the risks to the safety and welfare of baby, known as ‘Child A’”
John Harris, Independent chairman of Doncaster SCB, said: “What happened to Child A is very distressing. The findings and recommendations from this review are of huge importance in Doncaster and are informing the drive to improve safeguarding across the borough.
“The review enabled us to identify key learning points about the effectiveness of early help, the response to neglect, information sharing and pre-birth assessment and planning.
“A robust action plan was created, building on the findings, and many of the recommendations have already been acted on, but there is still more to do.
“Since this case occurred, a more robust approach to risk is being adopted, through the ‘Signs of Safety’ practice model, which is also improving the engagement between professionals and families.
“Better management oversight is also increasing the likelihood of risk being identified consistently and at the right time.
“As a result, the DSCB is confident that a situation like Child A’s is less likely to happen again.”