The murder of five-year-old Danielle Reid might have been avoided if health and social services had been better co-ordinated, according to a report.
Danielle Reid suffered a savage assault
Dr Jean Herbison's 196-page report did not blame any one individual for the Inverness girl's death.
But she said the risk to Danielle might have come to light if social work and health services had been operating at the "optimal level".
Agencies in the Highlands said they had already taken action on the findings.
Danielle's body was dumped in the Caledonian Canal in January 2003 after her mother's partner had attacked her.
Despite concern over Danielle's safety, social services failed to intervene and authorities lost track of the youngster when her mother withdrew her from school.
Lee Gaytor was jailed for life for Danielle's murder, and her mother, Tracy, received an eight-year sentence for her involvement.
Dr Herbison said there were similarities in her report to those into the deaths of children Carla Nicole Bone in May 2002, Caleb Ness in October 2003 and Victoria Climbie in February 2000.
"The findings reveal serious gaps in service provision to the vulnerable and at risk children," she went on.
"There has been an identification of lack of robust systems in place early enough to protect Scotland's children."
Tracy Reid received an eight-year prison sentence
She added: "There is little doubt that the violent death of this five-year-old was not directly preventable by any of the individuals concerned.
"Nevertheless, during my investigations it has become clear that there are major single agency and inter-agency failures, which could lead to continuing high-risk situations for children in the future."
She said that if social work and health services had been operating at an optimal level the potential risk to Danielle may have been recognised.
"There might then have been some possibility of avoiding her death," she said.
Her recommendations cover the roles of social work, police, education and health services in protecting children.
"There are local and national issues which require to be addressed urgently to prevent children suffering as Danielle suffered," she said.
"I hope that the recommendations of my report will be implemented in honour of Danielle."
Danielle's great-uncle, Nicholas Gordon, said: "These changes should have been made years ago.
"The family had no support from the agencies - that has to change. At least the investigation will help other children - I hope it will, anyway."
Education Minister Peter Peacock said many lessons had already been learned and changes made to systems.
"However, I have today agreed that child protection inspectors will double check whether there is anything arising from this report which would cause us to take further action - either nationally or locally," he said.
The Scottish Executive plans to give children a unique identifying number which will make it easier to transfer records when moving between schools.
Northern Constabulary's Chief Constable Ian Latimer, chairman of the Highland Child Protection Committee, said local agencies already complied with 65 of the 68 recommendations - and that there were moves to tackle the remaining three.