The "horrifying death" of Baby P "could and should have been prevented" but social workers and other agencies were too concerned with keeping mother and child together, a second serious case review found today.
Social workers, doctors, lawyers and police should have been able to stop the situation "in its tracks at the first serious incident" but their outlook was "completely inadequate".
The 17-month-old boy, who was found dead with multiple injuries on August 3, 2007, should have been placed in care, the review carried out by Haringey Local Safeguarding Children Board found.
More should also have been done to discover the role and identity of the mother's boyfriend. Council workers denied any knowledge of the man even though Baby P's father warned them he had seen the boyfriend at the family home.
Although agencies thought it was unlikely the mother was injuring the child nobody took the next step and looked into whether somebody else was involved, according to the executive summary of the review which was published today.
Even after the boy, who can now be named as Peter, was put under a child protection plan, his case was regarded as routine "with injuries expected as a matter of course".
The professionals tasked with the boy's protection were "lacking urgency", "lacking thoroughness" and "insufficiently challenging to the parent".