Starved Khyra, seven, missed 26 care agency appointments

Tragic details of the case are revealed in the first serious case review in the country to be published in full – a 180-page report by the Birmingham Safeguarding Children Board (BSCB) which strongly criticises the city's authorities.

Concerns about Khyra's welfare were raised by the public and school staff as long ago as March 2006, more than two years before she died and almost four years before her mother and stepfather were jailed for manslaughter.

A trial at Birmingham Crown Court heard Khyra had been removed from school in December 2007 and subjected to a punishment regime which included standing outside in the cold for long periods, having cold water poured over her and being beaten with a bamboo cane.

She and five other children in the care of her mother Angela Gordon, 35, and stepfather Junaid Abuhamza, 31, at their Birmingham home were deprived of food and prevented from entering the fully stocked kitchen by a bolt fixed out of their reach on the door.

But Birmingham Council was reluctant to intervene because Gordon was aggressive towards welfare agencies and filed a harassment complaint against a social worker who visited the house in February 2008. Three months later, Khyra was dead. She weighed only 2st 9lb when her body was found.

The BSCB report states: "There were a number of early missed opportunities for intervention.

"Three incidents during March 2006 were not progressed, either by failures of paperwork to reach the correct departments, failure to follow safeguarding procedures, or to conduct thorough checks prior to case closure, resulting in any knowledge and intervention remaining purely single agency at that stage."

It concludes: "Had there been better assessments and effective inter-agency communication over a period of time it (Khyra's death) could have been prevented."

The report made 18 recommendations for specific action and identified a further 53 areas for improvement targeting Birmingham Council, the city's primary care trusts, West Midlands Police, the Birmingham Children's Trust and the Safeguarding Board.

The council's Cabinet member for children, young people and families, Les Lawrence, said: "We realise that none of the improvements we and other agencies have put in place can bring Khyra back.

"For that we are profoundly sorry. The publication of the serious case review clearly highlights the opportunities missed by a number of agencies to intervene in the abuse being inflicted on Khyra by the people she trusted to look after her.

"As we remember Khyra Ishaq's life, we reaffirm our commitment to create a children's social care service that better protects our young people from those who would harm them."

A spokesman for the NSPCC children's charity said: "The tragedy of this case is that a number of people suspected something was going seriously wrong but no one was able to do anything to save Khyra.

"If concerns about a child are passed to social workers the public must be reassured that something effective will be done to protect them."

City's care agencies told to improve

Care agencies in Leeds have been told to improve after an independent panel found they missed chances to help a disabled girl who later died from a rare form of chickenpox.

The 13-year-old, identified only as Child R, died from chickenpox pneumonitis in 2008, four days after being sent home from hospital with a chest infection.

A serious case review found there had been "numerous missed opportunities" to support the girl during her life because her basic needs were "overshadowed" by mistrust between her mother and health professionals.

Details of the case are included in the review's executive summary, published by Leeds Safeguarding Children Board.

It reveals the girl, whose mother was only 14 when she conceived, was born with multiple disabilities including blindness and epilepsy.

Her mother managed her care, but "sometimes struggled" to attend all her appointments with health professionals.

The panel heard there were times when the mother raised concerns about her child but agencies "did not take the opportunity to intervene".

Leeds Council, West Yorkshire Police, NHS Leeds, and Yorkshire Ambulance Service NHS Trust all contributed to the review.

Jane Held, independent chairwoman of Leeds Safeguarding Children Board, said: "The death of this young person was a tragedy for her family and our sympathies are with them.

"A multi-agency action plan has been drawn up. This plan makes clear what we need to do to improve how we offer support in the future."