An investigation into the death of a baby in Plymouth through neglect says there was a "fundamental failure" to protect him.
Perrin Barlow: Coroner wants investigation into his care
Perrin Barlow was nine months old when he died in July 2002 in a city flat.
Perrin's mother Stephanie Horrocks, a drug addict, and partner Mark McAndrew, were jailed last year after admitting child cruelty. Horrocks died in jail.
A report into the case makes 39 recommendations to social services, the police, doctors and other agencies.
The report, released by the city's multi-agency Area Child Protection Committee (ACPC), reveals there was a "fundamental failure" to protect him from harm.
The ACPC said the recommendations were made "to ensure that lessons are learned and children in Plymouth are safeguarded".
The report calls for a review of child protection training within the council's social services department.
John Baker, director of Plymouth social services, said: "We will, of course, act on the recommendations from the ACPC and have already implemented many of the recommendations outlined in the executive summary.
"I'm confident that the improvements already made ensure that we have the right procedures, processes and people to enable us to safeguard children in Plymouth, and I know child protection is at the forefront of everyone's minds.
"Perrin Barlow's death was tragic and we have been doing everything possible to ensure that lessons are learned as a result of this case, in order to prevent similar tragedies in the future."
Plymouth Council is fighting to block a coroner's investigation into the death of Perrin who was on the social services "at risk" register.
The council's social services department says the circumstances of Perrin's death have already been exhaustively investigated.
But the coroner insists there has never been a sufficient public investigation into the background circumstances of the death.
He says that Article 2 of the European Convention on Human Rights - which enshrines the "right to life" - demands that the inquest jury consider whether "system neglect" by social services contributed to his death.
The High Court is due to give a ruling on the issue in the next few weeks.