The serious case review asks that nine recommendations are implemented across the agencies following toddler Ayeeshia's murder.

They are:

1: The mental health issues and drug use of parents should always be assessed as part of child safety.

2: Agencies must review their professional supervision and training of staff to ensure that they adequately address the need for closer supervision.

3: Any child who is returning to a carer where there have been safeguarding concerns should have a child protection plan running parallel to a supervision order for at least the first six months.

4: Derbyshire Safeguarding Children Board should undertake a multi-agency audit of children subject to a supervision order to ensure care plans are robust.

Ayeeshia-Jayne Smith was failed by the system SIX times, serious case review reveals

5: Where there are safeguarding concerns for children, fathers and other male partners must be adequately supported, consulted and assessed in the care of children even if they are not the primary carer.

6: Medical staff must ensure that they always consider abuse or neglect within their diagnosis when considering the reasons for a child's injuries or illness. This should be recorded and appropriately risk assessed.

7: Both Derbyshire and Staffordshire social care and health care partners should ensure that child protection information is properly shared between partners.

8: Missed medical appointments for children known to social services should no longer be recorded as did not attend - but always seen in the context of 'was not brought', to ensure that parental neglect is considered a factor.

9: Agencies should consider how more robust assessments are undertaken when vulnerable parents with children, where there are safeguarding concerns, are housed. These assessments should consider the risks associated with housing being offered and its suitability in relation to age of the children.