A major review into the case of Star Hobson has found that family members were "not listened to" in the months before her murder.
A panel of child protection experts was asked to carry out an investigation after the "palpable public shock" over the deaths of Star, in Keighley, and that of six-year-old Arthur Labinjo-Hughes, in Solihull. The two children were murdered within months of one another in 2020.
The panel's report highlighted a number of "missed opportunities" in both cases and said concerns raised about the plight of the two children were "disregarded and not taken sufficiently seriously".
Leading social worker Annie Hudson, who chaired the panel, said: "Star’s wider family members were not listened to.
"The growing weight of concerned voices speaking on behalf of Star should have prompted professionals to reconsider the escalating risks to her."
Star's great grandfather David Fawcett told ITV News: "If social services had done their job properly, I definitely know that Star would have been here."
David Fawcett speaks to ITV News
Star was 16 months old when she was murdered by her mother's partner, Savannah Brockhill, at their home in Keighley, on 22 September 2020.
She suffered a fatal cardiac arrest after months of "neglect, cruelty and injury" at the hands of Brockhill and Star's mother, Frankie Smith.
What did the report say?
The 133-page report, by the Child Safeguarding Practice Review Panel, was produced after Star and Arthur died to answer questions about "why children had experienced such gross abuse and suffering when they were seemingly in 'plain sight' of public agencies".
It describes Star as an "inquisitive toddler who loved to listen to music and would dance in her baby walker, laughing and giggling".
But it highlights a number of occasions when family and friends raised concerns about apparent physical injuries suffered by the toddler, including bruising to her face and body.
On one occasion a video showing what looked like finger-mark bruising on Star's face was shared among members of the family.
Despite visits from social services and police, these concerns did not lead to direct intervention and the authorities accepted Smith's repeated claims that allegations against her and Brockhill were "malicious".
Seven days before Star died, her case was closed by Bradford children's social care on the basis that the concerns were "unsubstantiated".
The report said: "Framing family concerns as being 'malicious' was inappropriate and distracted professional attention from what might be happening to Star."
What went wrong?
Bradford Council's children's services was rated "inadequate" in 2018 and the report said that Star's experience reflected the overall failings of the service.
It said visits to Star's home were "one off" and superficial, and assessments were not fit for purpose.
Bradford children’s social care service was "in turmoil", the panel found, with professionals working in conditions that made "high quality decision making very difficult to achieve".
The volume of work staff were expected to carry out and the high turnover of staff made effective child protection difficult.
What happens now?
The panel said the child protection system nationally must be "strengthened".
It said: "We believe that the way we approach child protection in this country needs to change fundamentally... too often we see critical, life-changing decisions being taken for children by children's social care alone or with only superficial and partial involvement of other agencies.
"We need to see genuinely joint, challenging, rigorous decision making every time there are concerns."
The panel made a number of recommendations, the primary one being that multi-agency child protection units should be set up across the country, including officials from police, health and social care services.
The education secretary Nadim Zahawi said: "We must waste no time learning from the findings of this review – enough is enough.
"I will set up a new Child Protection Ministerial group, a first and immediate step in responding to these findings, before setting out a bold implementation plan later this year to bring about a fundamental shift in how we support better outcomes for our most vulnerable children and families."
Reacting to the report, the NSPCC said the review "tells an all too familiar story of a system struggling to cope".
Head of campaigns Helen Westerman said: "Political will and leadership from the very top of government are now needed to create a system that works to prevent harm and responds decisively to keep children safe in local areas."
Bradford Council said it was working with a Government-appointed Children's Commissioner to make improvements.
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