Cardiff and Vale of Glamorgan Regional Safeguarding Children's Board's extended child practice review of the case found that the emerging pattern of injuries inflicted on Elsie by one of her adoptive fathers were missed because professionals saw the adoption as highly successful.
"The professionals involved with the child viewed the adoptive placement as being very successful; the events in the child's life were viewed through a ‘positive lens'," states the review. "This is the case for the majority of children placed for adoption.
"It is clear… that this family were perceived to be very positive parents for the child. Given how strongly this view was held, the injuries that the child sustained were never considered as anything other than childhood accidents."
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