A baby who was murdered by her father had been seen by 30 health workers before she died, care bosses admitted.
Andrew Randall admitted murder and causing grievous bodily harm
Jessica Randall was killed in 2005 by her father Andrew, who also sexually abused the 54-day-old at her home. He was jailed for life in March 2007.
A report into Jessica's death, in Kettering, Northamptonshire, has also concluded a number of care agencies failed to identify her as at risk.
Health agencies and council chiefs have promised to act on the report.
Northamptonshire Teaching Primary Care Trust confirmed Jessica died after 30 members of staff at Kettering General Hospital and the trust had failed to begin child protection procedures.
However, the Safeguarding Children Board for Northamptonshire report, released on Wednesday, stopped short of blaming any individuals for her death.
"In recognising that opportunities had been missed to identify signs of abuse we must conclude that the outcome for Jessica Randall may have been different had these signs been acted on," the report concluded.
It also stated that, as early as 12 October 2005, "there were grounds for a referral to Children and Young People's Service (CYPC) due to her mother's previous history of mental health problems".
By 15 November, six days before Jessica died, "there were significantly more concerns and "some formal discussion" should have been made with the CYPC, which is part of Northamptonshire County Council.
But it accepted Jessica's father did not have a criminal record and there was nothing in his medical records to suggest he was a danger to her.
The hospital has confirmed its 2000 staff have since received training in spotting cases of child abuse.
But Dr Brendan O'Malley, medical director at the hospital, said: "The report was not a whitewash.
"We looked very carefully at it and we really considered that it was the processes that were remiss. The individuals now know very clearly from training what they need to do in the future."
Asked to clarify what the doctor who had seen Jessica just days before she had died had failed to do, he added: "When Jessica was first presented to us she was twitching and the doctor felt she was probably fitting.
"He felt there were several possibilities for the diagnosis behind this and he set a range of investigations in motion.
"He organised a chest X-ray and an MRI scan but they all came back negative."
Other examinations were carried out, but none appeared to indicate evidence of child abuse.
"The system was there but the problem was that it had not been triggered and the lesson that we have learnt is that we need to raise people's awareness of what has to trigger off referral to making a child at risk," he said.
Paul Burnett, director for children and young people at Northamptonshire County Council, said: "We, along with our partners, acknowledge all of the mistakes which were made and we have already taken action to address the key findings of this report to ensure that our services for children are improved as proposed."
Randall, then 33, of Havelock Street, in Kettering, was jailed for life after admitting murder, causing grievous bodily harm and four counts of sexually abusing Jessica.