A number of questions are posed about the handling of the case of 17-month-old Tahla Ikram, who died after abuse by his father Abid Ikram and his stepmother Sumairia Parveen.
The death prompted an independent inquiry by the Ealing Safeguarding Children Board.
WHEN DID SOCIAL SERVICES BECOME INVOLVED?
Tahla and his family had been known to various agencies since 1997 and was under the care of social services shortly after his birth because there were concerns about the mental health of the biological mother.
However, social services said there was no concern regarding Ikram's ability to care for the child even though he lied about his on-going relationship with the mother and the access he allowed her to have to Tahla while she was given treatment for her personality disorder.
WHY WAS TAHLA RETURNED TO HIS FATHER?
The final decision on returning Tahla to his father was made by a judge. He took into account a psychologist's report on Ikram and Parveen which said they were both safe parents.
A report into the handling of Tahla's case does say the psychologist never spoke to Parveen on her own and she was always in the company of Ikram which may and have inhibited her from speaking freely about her true feelings for the child.
Tahla was placed with foster parents when he was taken away from Ikram and social services noted he progressed well under their care. But the foster parents agreed the preferred way forward was placing the boy permanently with Ikram.
Tahla was then placed with Ikram under a supervision order.
WHY DIDN'T DOCTORS NOTICE ANYTHING WRONG?
Ealing Hospital, where Tahla was taken to A&E, has said its doctors did consider recording Tahla's injuries as non-accidental.
But a spokesman for the west London hospital said it did not have access to his records as Tahla was not on the child protection register as he was only under a supervision order.
Doctors said Tahla's injuries were like those of a car crash victim
A spokesman for the hospital did say they should have questioned the father more about his social services history and the doctors could also have spoken to a social worker at the A&E. The spokesman added the hospital "regretted" that it did not do so.
The inquiry report also said recording on medical notes why an injury was deemed non-accidental would have meant the diagnosis of deliberate harm would have been more likely to be considered.
The report added the problems may have been compounded by the recent rotation of doctors which take place at the hospital twice a year. It said the when Tahla was first taken in he would have been seen by doctors new to their posts and would have had very little clinical experience.
WHAT LESSONS CAN BE LEARNED?
The report into Tahla's death says: "At no time could it have been predicted that Tahla would be seriously physically harmed by his carers."
But it does make some recommendations.
It highlights the need to review the link between supervision orders and the child protection register (CPR). If Tahla had been placed on the CPR at the time he was placed under the supervision order, doctors at Ealing Hospital, and other agencies, would have been able to access his social services history.
The report also called for better communication between agencies especially between the two social services departments involved at Hammersmith and Fulham and Ealing.
Doctors at A&E should ensure when treating children who may be at risk, they should also take a full social history as well as a medical one.
The spokesman for Ealing Hospital has said many of these recommendations have already been implemented.