A review into the death of a seven-year-old boy found chance after chance was missed to save his life.
Blake Fowler, from Shirley near Southampton, suffered a catalogue of sexual, physical and emotional abuse leading up to his death from head injuries in December 2011.
A Serious Case Review found teachers, social workers and doctors all overlooked clear and obvious signs, even after he told his school "I get bruises from daddy."
Concerns for ill-treatment were first made in November 2007 and despite numerous contact between Blake and the health and social care services, he remained with his family until his death more than four years later.
This was despite their being reports the child was being given vodka to drink and either being allowed to or being forced to watch pornographic films with his mother and her partner.
Several services missed up to 18 individual chances to intervene in the abuse of Blake, including a letter from his grandmother to the local authority saying: "I just don’t want to take that phone call to hear that something has happened to either my daughter or my grandchildren,” just months later Blake was dead.
It is a mark of his resilience that he continued to present much of the time as lively and cheerful, but the failure to see that this presentation masked a lifetime of abuse is alarming. This was not a case which required particular investigative expertise or determination. Evidence of abuse and neglect was repeated and explicit.
Some of the missed opportunities to help the boy included:
October 2005 - At 14-months-old Blake was treated in hospital for facial bruising, said to be caused by a fall, and old burns, said to be caused by accidental contact with a hot iron.
December 2007 - Police contact the council over reports Blake was 'violently hit' in a supermarket.
June 2008 - NSPCC is called by workmen near Blake's home who were concerned after allegedly seeing him with injuries to his face.
August 2008 - Grandmother tells social services Blake has a black eye. Social worker said he would follow it up 'when he had time'. No evidence that this was followed up was found by the review.
September 2008 - Days before starting school, Blake is admitted to hospital with facial injuries and a painful, swollen penis. He gave what appeared to be rehearsed responses to staff including: 'I walked into a door'. Despite the consultant paediatrician giving his opinion that the injuries were deliberately inflicted, no further action was taken after an assessor visited the family home but without actually seeing Blake.The review said this was 'the most significant missed opportunity'.
April 2010 - Blake seen by school staff with bruising to his head.
January 2011 - His school again notes bruising to Blake's face. Staff also note Blake mimicking sexualised behaviour.
June 2011 - Blake attends school with a black eye.
December 3, 2011 - Blake is taken to Southampton General Hospital in with serious head injuries, where he dies the following day.
Blake's mother, stepfather and step-uncle were arrested last year but the Crown Prosecution Service ruled that no further action would be taken against them due to lack of evidence.
Blake was only seven years old when he died in 2011. His family were well known to local services in Southampton as a result of domestic abuse and there had been long-term concerns about Blake's safety.
When the case was re-investigated last year, Hampshire police's Assistant Chief Constable Laura Nicholson apologised "that the initial investigation by the constabulary was unsatisfactory".