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The first serious case review in England to be published in full was released today.
The review on the case of seven-year-old Khyra Ishaq who starved to death at her home in Handsworth, Birmingham in 2008 concluded that her death could have been prevented.
Birmingham Safeguarding Children Board (BSCB) found that despite concerns being raised by members of the public and school staff about Khyra's welfare, information was not acted upon and safeguarding procedures were not properly followed.
The case review found that some agencies "lost sight of the child and focused instead upon the rights of the adults, the adults' behaviour and the potential impact for themselves as professionals".
Hilary Thompson, chairwoman of the BSCB, said: "The serious case review concludes that although the scale of the abuse inflicted would have been hard to predict, Khyra's death was preventable.
"The report identifies missed opportunities, highlighting that better assessment and information-sharing by key organisations could have resulted in a different outcome."
Until today only executive summaries of serious case reviews have been published in cases where children have died or been harmed. Following several high profile cases including the case of two young brothers from Edlington who beat and tortured another pair of boys, the Baby P case and Khyra's case, the Conservatives promised ahead of the General Election that they would publish serious case reviews in full. Soon after the coalition was formed, the government announced the change along with an independent review of child protection and social work in England.
In March, Mr Justice Roderick Evans sentenced Khyra's mother, Angela Gordon to 15 years and jailed her former partner, Junaid Abuhamza indefinitely with a minimum term of seven and a half years.