This serious case review report concludes that it is very likely Callum Wilson's death could have been prevented.
But "missed opportunities" meant the 11-month-old's mother killed him and no one who could have done or should have done intervened to protect him.
It concludes that:
This points the blame at key front line workers.
In the months and weeks leading to Callum's death the report records that a social worker noticed scratches on Callum's face on a home visit, his GP noticed bruising on his face and head, and staff at a children's centre where his mother took him noticed scratches and bruises on him on several occasions.
But no one, the SCR reads, reported any of their concerns to the Local Authority.
The SCR concludes that the risks Callum faced were consistently underestimated, and that he should have been much more closely monitored.
It says that there are important lessons that have already been learnt about the training, skills and knowledge of individual professionals and by the teams involved about the need to better share information between agencies.
But there are issues beyond the individuals concerned, failures in the system too:
It notes that the caseloads of health visitors in the area, East Berkshire, exceeded national recommended levels, which limited the time staff had to make assessments and make visits.
One local councillor has already alleged that cuts to local services are compromising services.
Another damning conclusion is that the current arrangements for the transfer of GP records (information sharing) was "not fit for purpose" in relation to the needs of vulnerable children like Callum.
It also points out that with hindsight, another mistake was giving primary responsible for the case to a "newly qualified and inexperienced social worker" and that the "potential complexity of the case was underestimated".
Those involved in the serious case review expressed their "sincere sympathy to those who loved Callum in his very short life".
It states that all the recommendations have already been implemented.