Rebecca Kandare died in January 2014 as a result of severe malnourishment, bronchopneumonia and rickets. Her parents, Brian Kandare, 29, and Precious Kandare, 37, of Wednesfield, admitted manslaughter and were jailed for 9 and a half years and 8 years respectively.
Nottingham Crown Court heard the couple had failed to seek urgent medical care for their daughter because of their religious beliefs. Rebecca's siblings have been taken into care.
The Serious Case Review looked at the involvement various agencies had with Rebecca and her family in a bid to identify whether anything could have been done differently which may have prevented her death.
The final report, by independent author Birgitta Lundberg, makes a number of recommendations, including ensuring professionals have a better understanding of how religious beliefs may impact upon a child's health and development and improving the way agencies work with families who are reluctant to engage with services.
It also highlights the need for better information sharing and recording and the importance of reassessing an individual's circumstances when new events or information come to light.
All of these recommendations have subsequently been implemented.
Alan Coe, Chair of Wolverhampton Safeguarding Children Board, said: "On behalf of Wolverhampton Safeguarding Children Board and the agencies involved in this case, I would like to express our deep sorrow at Rebecca's death.
"It was an appalling tragedy. Her parents, to whom she should have looked to for care and support, failed to provide them, and they have been rightly imprisoned for their crimes.
"The Safeguarding Children Board held this Serious Case Review to ask 2 questions - was there anything more the agencies involved could have done, and should they do things differently to potentially avoid something similar from happening in the future.
"We must be very clear - Rebecca's parents were responsible for her death. They did everything they could to disguise their neglect of their daughter while superficially complying with health professionals in particular.
"However opportunities were missed to intervene - and had they been taken it might well have made a difference; that is a bitter disappointment to all concerned.
"The report highlights a number of areas where improvements should be - and have subsequently been - made, including in the ability of practitioners to detect and assess parental cultural and religious beliefs which may affect the basic care of a child.
"It also identifies the need to improve the way agencies work with families who are reluctant to engage with agencies, the importance of updating or reassessing a child's circumstances when new information comes to light, and
Improving information systems, recording practices and the quality of communication between agencies and professionals where there are concerns about a child.
"In total the report makes a number of specific recommendations for the Board and the agencies concerned, all of which have been implemented.
"Furthermore, the introduction of Wolverhampton's new Multi Agency Safeguarding Hub is having a hugely positive impact on safeguarding. It has brought together professionals from a variety of statutory and voluntary agencies that have contact with children, young people and families, making the best possible use of their knowledge and information to keep vulnerable people safe from harm.
"We are in a better place than we were at the time of Rebecca's death, and while it is impossible to say that such a tragedy could never happen again, I am confident that the likelihood of it doing so has been greatly reduced."
The Serious Case Review Panel included representatives from Wolverhampton Clinical Commissioning Group, the Royal Wolverhampton Hospitals Trust, the City of Wolverhampton Council's Early Years, Social Care and Safeguarding departments, Wolverhampton Community Safety Partnership and West Midlands Police. A representative from the voluntary sector and an advisor on culture and faith were also part of the Panel.
A copy of the Serious Case Review Overview Report, together with agency action plans, is available on the Wolverhampton Safeguarding Children Board Type=links;Linkid=7041;Title=website;Target=_blank;.
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- released: Monday 21 March, 2016