The Serious Care Review outlined six failures of the agencies involved with Ayeeshia-Jayne Smith, known as AJ:
Finding 1 : The child protection plan which AJ and her mother were put on did not consider whether the mother should be subject to a more detailed assessment to fully explore the implications of her mental health needs and drug use on her capacity to parent.
Finding 2 : There was not enough evidence of authoritative professional practice that saw AJ as the primary client and this resulted in a fixed view that attachment and parenting continued to be good enough as risks increased.
Finding 3 : There is a lack of understanding by professionals about their role and responsibility when a child is subject to a supervision order that can result in a lesser degree of protection than when a child is subject to a child protection plan.
Finding 4 : There was little recognition of the role the boyfriend Matthew Rigby and the child's father played in AJ's life. This resulted in a lack of professional assessment of both the benefits and risks they posed to both the mother and AJ.
Finding 5 : Emergency department and paediatric staff did not sufficiently consider whether child abuse or neglect was a possibility when AJ presented with medical issues during the last few months of her life.
Finding 6 : There was insufficient consideration of the importance of the provision of suitable housing for Smith and the impact it had on AJ.
The NSPCC has also criticised the agencies involved saying that lessons needed to be learned.
A spokesman said: "Defenceless Ayeeshia-Jayne suffered sickening cruelty and was consigned to a brutal death by the people who should have protected her.
"The child must be at the heart of all decisions that professionals make in these situations – no matter how difficult those decisions may be.
"This report has revealed a series of missed opportunities and flawed practices that did not consistently prioritise Ayeeshia-Jayne's needs – and must now be addressed and improved.
"'Lessons need to be learned' is an all-too-familiar phrase in tragic cases like this – but everything possible must be done to ensure swift and decisive action is taken when there are concerns for a child’s welfare.
"It is vital that anyone worried about a child speaks out, as it could save a life. They can contact the NSPCC helpline in confidence, 24/7, on 0808 800 5000."