By Nick Triggle
Health reporter, BBC News
The NHS had 35 contacts with Baby P before he died
A catalogue of failings by the NHS meant a series of opportunities that could have saved Baby P's life were missed, the health regulator says.
The toddler - now named as Peter - from Haringey, London, had been seen by health services 35 times by the time he died after horrific abuse in 2007.
Two doctors involved in his care have already been suspended.
But the Care Quality Commission said Haringey's services were poor, leading to an apology from NHS trusts involved.
Baby Peter had suffered more than 50 injuries by the time of his death in August 2007, aged 17 months.
The catalogue of abuse he suffered emerged during a court hearing at the end of last year that led to the conviction of his mother, her boyfriend and their lodger for causing his death.
The case led to heavy criticism of local social care arrangements with some council staff losing their jobs as a result.
The 35 contacts with the NHS covered visits to a GP, health visitors, consultant paediatricians, hospitals and walk-in centres.
The regulator criticised three trusts in particular - Haringey, which was responsible for the community services, North Middlesex Hospital and the specialist children's hospital Great Ormond Street, which provided the paediatric staff for both the local trusts.
It said system failure meant medical records were not shared between different health services and NHS workers did not properly alert social services and police to their concerns.
Staff shortages and delays in assessments were also noted.
Despite this, all three trusts have in previous years reported that they complied with official standards covering child protection.
This issue is now central to the second report the CQC is compiling into the way the rest of the NHS carries out child protection duties.
But the CQC pointed out that staff did not follow protocols when they were in place.
Bone and skeleton scans were not always carried out to give a clear picture of Peter's injuries.
The report said the consultant who saw Peter two days before his death and noted bruises and marks over his body did not alert a social worker.
The paediatrician was Dr Sabah al-Zayyat, a locum who is one of two doctors suspended and being investigated by the General Medical Council.
She did not carry out a full examination of Peter - allegedly because he was miserable and cranky.
THE MISSED OPPORTUNITIES
Six recorded visits to hospital, two of which were to an A&E unit
GP saw Peter 14 times, the last of which was a week before his death. The doctor is under investigation
One visit to a specialist health service. Paediatrician now suspended
Five visits made to Peter at home by health visitors
Two recorded visits to walk-in centres
Other contacts include mental health workers and parenting counselling service
A post-mortem examination later revealed a broken back and ribs, among a number of other injuries, that are believed to have pre-dated his appointment.
The regulator also highlighted the role of Peter's GP, Dr Jerome Ikwueke, the other medic under investigation.
The report said as the central medical record holder he could have identified the recurring visits to hospital "as a signal of potential abuse".
CQC chief executive Cynthia Bower said: "There were clear reasons to have concern for this child, but the response was simply not fast enough or smart enough.
"The NHS must accept its share of the responsibility."
The three trusts criticised said they had already started changing and improving procedures.
Great Ormond Street Hospital said it was "truly sorry Peter suffered and died".
And Tracey Baldwin, chief executive of Haringey Primary Care Trust, apologised, adding: "We failed to understand the level of danger that Peter was in."
But Health Secretary Alan Johnson said: "These failures are unacceptable. We must do all we can to learn the lessons of this appalling case."