A boy died from a severe head injury after authorities failed to act for years while he suffered abuse, a serious case review has found.
There had been "long-term concerns" about Blake Fowler's safety, the Southampton Local Safeguarding Children Board concluded.
Blake, 7, died at his home in Southampton in December 2011.
His mother and stepfather were arrested, but prosecutors dropped the case through lack of evidence.
In December, the Crown Prosecution Service (CPS) decided no further action would be taken against Sarah Spacagna and Peter Meek.
An inquest in 2013 heard they were guilty of an "appalling and disgraceful failure to prioritise the needs of Blake" and had fallen "woefully short" as parents.
Missed opportunitiesKeith Makin, of the Southampton Local Safeguarding Children Board, said: "His family were well known to local services in Southampton as a result of domestic abuse.
"The serious case review highlighted several missed opportunities to help Blake and a number of significant failures in our child protection system."
The board said the "errors made in this case were simply unacceptable".
The first allegations of ill-treatment of Blake were made in November 2007.
The report found staff at the pre-school and the school attended by Blake failed to make child protection referrals on a number of occasions, despite explicit evidence of injury and inappropriate sexualised behaviour.
'Unacceptable failings'In one example, just before starting school in September 2008, Blake was referred to Children's Social Care Services (CSC) by Southampton General Hospital after presenting with a bruised penis and facial injuries.
The consultant paediatrician specifically gave a view some of Blake's injuries had been deliberately inflicted.
The review said this hospital admittance was a particularly "significant missed opportunity".
Southampton City Council said it apologised for the "unacceptable failings of the city council during Blake's life and at the time of his death in 2011".
The council said it has since set up a new group - a multi-agency safeguarding hub, Mash which had "transformed the way we work to protect children, providing a coordinated and timely response".
The service involves the police, health and social security departments pooling resources in dealing with cases.
Boy died after abuse case 'failings'
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