By Lisa Dowd, Midlands Correspondent
Chance after chance was missed to intervene in the case of a tragic four-year-old boy who was beaten to death by his mother and stepfather.
A serious case review into the death of Daniel Pelka found repeated failures by agencies set up to safeguard children's welfare.
But it concluded that nobody could have predicted his death at the hands of an abusive mother and stepfather last year.
Daniel was brought up in a chaotic family where violence and heavy drinking was the norm. He was known to police, social services, teachers and doctors.
Magdalena Luczak and Mariusz Krezolek were both jailed for life But the report found that not one professional asked him what was going on at home.
Ron Lock, the independent author of the report, said: "He didn't speak good English.
"His self-esteem was so low, he was a very isolated little boy so people found it hard to engage him.
"His mother often spoke on his behalf, as did his older sibling, so rather than ask Daniel others were asked what he was thinking and to ask his mum and older sibling was not going to give the correct answers."
Daniel was terrorised at his home in Coventry by his mother Magdelena Luczak, and his stepfather Mariusz Krezolek.
The four-year-old had 40 injuries on his body when he died He was starved, beaten and force-fed salt.
At school he rooted through bins for food and he once turned up with two black eyes. He later died from a serious head injury on March 3, 2012.
The review found that the couple misled authorities by lying about his injuries and pretending he had an eating disorder, rendering Daniel "invisible" to health professionals.
But it also highlighted how stretched children's services were in the city.
It describes overworked staff who were "naive", who were not "inquisitive", who assumed others were "intervening" and were not prepared to "think the unthinkable".
It noted missed opportunities to help Daniel, including 27 reports of domestic violence to police.
In January 2011 he went to hospital with a broken arm - a spiral fracture suggested twisting - but professionals were too ready to accept it was accidental.
In September - when Daniel started school - teachers noticed a pattern of injuries which they failed to record or act on.
In February 2012 he saw a community paediatrician - his weight loss was not recognised and child abuse was not even considered.
A few weeks later the four-year-old was dead. He had 40 injuries - a doctor said he looked like a concentration camp victim.
Martin Reeves, chief executive of Coventry City Council, said: "Professionals didn't have the whole picture. Daniel's voice wasn't heard at all.
"Arguably they are basic errors but we have to put this against a backdrop of social care workers, police, health colleagues working every day making what some would argue are impossible judgment calls on child protection so I think our key now is how do we learn from those issues."
The review, by the Coventry Safeguarding Children Board, has published 15 recommendations aimed at preventing such a failure happening again.
Luczak and Krezolek, both originally from Poland, were convicted of Daniel's murder in a trial earlier this year and are now both serving minimum 30-year terms in prison.
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