The National Children's Bureau (NCB) have responded to the serious case review into the death of two-year-old Keanu Williams who was beaten to death by his mother in 2011.
This case starkly demonstrates the unintended consequences of recent reforms to child protection; an overly bureaucratic process; lack of individual responsibility; increasingly complex organisational relationships and responsibilities; and no one advocating in the interests of the child.
It is particularly worrying that the review found that no conversations were held with Keanu to find out what he was feeling.
No child at risk should ever be only seen and not heard. We urgently need to review how best to support children within the child protection system - especially the very young ones - to ensure their voices are listened to at every opportunity.
Following the conviction of Amanda Hutton, questions are raised over two little boys killed by those who were supposed to care for them.
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More than 10 social workers and health workers have been sacked or resigned over the death of a two-year-old who was killed by his mother.