The report, by Calderdale Safeguarding Children Board, found that Calderdale care services and combined health services showed particularly serious shortcomings in the case of Child C, whose parents were convicted of offences of child cruelty.
The review said although the child, whose mother was a drug user and had had two previous children removed from her care, was on the child protection register, "an unrealistically positive" view was taken of her parents' capacity to provide adequate and safe parenting.
It cited a lack of management by health and care services, poor communication between agencies, significant delays in family assessments, poor levels of contact between the allocated social worker and the parents, and systematic failures in care services as factors in the case.
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