Daniel Pelka review explains what went wrong but not why

This Serious Case Review is long on harrowing detail but short on helpful conclusions.

In other words, this report is strong on what went wrong, but weak on explaining why it was allowed to happen.

Tragically for Daniel, the report makes clear there are no shortages of people to blame. It catalogues the failures of almost every adult he knew, every agency who should have protected him and didn't.

By my count, there were 42 opportunities where professionals could have intervened to save Daniel, and they were all missed. There's the paediatrician, for example, who did not report Daniel’s extraordinary loss in weight, but rather suggested that "iron syrup, zinc tablets and vitamin drops" be prescribed over the next six months. His mother never even picked up the prescription.

Then there were the health visitors who never met Daniel but who should have done; and the social workers who decided that it was an accident when Daniel’s arm was broken by his stepfather in a fit of temper, but who closed the file on him.

Page after page it goes on. What about the teachers who complied with his mother’s demands not to give Daniel extra food, even though he had only half a sandwich each day in his lunchbox, looked like a famine victim, and was stealing food?

And what about the police who appear to have treated frequent call-outs to Daniel's home in response to violent domestic abuse - as if they were responding to a parking irregularity.

But before the witch hunt begins, lets take a step back and look at the wider picture which reveals a local authority safeguarding system that had grown so over-complex that no one in the entire process appears to have used their common sense.

In fact, it would appear to me that no one noticed Daniel at all, let alone talked to him.

Yes, his mother was a skilful, manipulative liar. But Daniel wasn't; he was a frightened little boy.

One child protection expert I spoke to was full of anger after reading the report - but probably closer to despair, telling me that Daniel Pelka, like Baby P before him, probably "got lost in the complex world of local safeguarding children boards, joint strategic needs assessments, compliance and data protection."

Social workers, too, tell me that a new system meant to help them, the Integrated Children’s System, an electronic database, has actually chained them to their desks entering information when they should be out visiting families.

This Serious Case Review is made up of 69 heartbreaking pages cataloguing the failures which allowed Daniel to die at the hands of his mother and step-father - but only 15 containing lessons learnt.

It helps us to understand what happened to Daniel, but tragically not yet why.

Until we know that, we can't be sure that other vulnerable children will be safe in the future.