A Government minister has expressed his "deep concerns" over a serious case review (SCR) into the death of a four-year-old boy who was starved by his mother, saying it has failed to fully explain "missed opportunities to protect children in the house".
Children's minister Edward Timpson was responding to the publication of the SCR into the case of Hamzah Khan, whose decomposed body was found in a cot in his Bradford home in 2011, almost two years after he died.
Mother-of-eight Amanda Hutton, 43, was jailed for 15 years last month after she was found guilty of Hamzah's manslaughter and neglecting five of her other children.
At her trial it emerged how a range of agencies had contact with her family but no-one spotted the danger the children were in.
The SCR into that contact concluded that Hamzah was "invisible for almost a lifetime".
The minister wrote to Professor Nick Frost, who chairs the Bradford Safeguarding Children Board, today saying: "I have deep concerns over the Hamzah Khan serious case review.
"In particular, I am concerned that it fails to explain sufficiently clearly the actions taken, or not taken by children's social care when problems in the Khan family were brought to their attention on a number of occasions."
Mr Timpson set out a series of question he believed needed answering relating to the contact different agencies had with Hutton and her family.
He said: " All of these were missed opportunities to protect the children in the house.
"It is tragic beyond words that by the time a health visitor did trigger concerns about the whereabouts of the younger children in the household, who were missing from health and education services altogether, Hamzah Khan was already dead."
At a press conference in Bradford, Professor Frost denied the report he ordered was a "whitewash" and stressed that it had been undertaken by independent people.
He said: "It's not a whitewash. I will undertake the action requested by the minister. We are totally committed to transparency in this case."
Alcoholic Hutton was living in ''breathtakingly awful'' conditions with five of her young children as well as Hamzah's mummified remains when shocked police entered her four-bedroom house in September 2011.
A jury at Bradford Crown Court found she had allowed Hamzah to starve to death in December 2009 and left his body in a cot with a teddy.
The remains were only discovered due to a rookie police community support officer's tenacious pursuit of a minor anti-social behaviour complaint because she knew something was wrong.
The family was known to all the main agencies, partly due to a long history of violence Hutton suffered at the hands of Hamzah's father, Aftab Khan
But Hutton failed to co-operate with many children's services and the SCR found that Hamzah slipped below the radar and was invisible.
He missed a range of health-related appointments and t here were no medical records on him from the age of two weeks until he died, aged four and a half.
His GP eventually removed him from his list.
Prof Frost concluded: " The SCR is very clear that Hamzah's death could not have been predicted but finds that systems, many of them national systems, let Hamzah down both before and following his death."
He said: "In my 35 years of involvement in children's services, I have never come across a case that can even be compared to this one.
"No child should go through what Hamzah experienced. I am satisfied that systems are in place today that minimise the chance of a situation such as this ever being repeated in Bradford."
Prof Frost and the director of children's services in Bradford, Kath Tunstall, insisted Hamzah's predicament had not been picked up due to systems failures rather than individual professionals' mistakes.
Ms Tunstall said: "We are all sorry with what's happened in this case and in this family.
"The person responsible for the death of Hamzah is, very sadly, his mother, Amanda Hutton.
"That was the conclusion of the judge and that was the conclusion of the serious case review."
Under repeated questioning about the culpability of people in her department, Ms Tunstall said: "There is no evidence in the information that's been considered that says that an individual was responsible."
And she denied her imminent retirement had any connection with this case.
Prof Frost, Ms Tunstall and the SCR's independent chairwoman, Nancy Palmer, all stressed there was never any concerns raised about the family that "met the threshold" for statutory action by social workers.
Ms Palmer said: "The panel concluded that the information known to the various agencies at the time of the events does not suggest that Hamzah's death was a predictable event."
She said: "None of the various organisations that came into contact with the family had enough information to form a view about what life was really like for any of the children in this household, especially during the last few years."
The SCR report published today said: " Information known to the various agencies at the time of the events that have been examined and analysed by the panel does not suggest that Hamzah's death was a predictable event."
It said inquiries into where Hamzah was did begin in 2010 - after he had died.
Hutton convinced professionals that the children were staying with relatives in another part of the UK despite giving inconsistent accounts.
The report said: " The ability to persuade several services that the younger children including Hamzah were no longer living in the city and had effectively disappeared will require thoughtful reflection in regard to the prevention of children going missing at local and national levels."
It added: " The fact that Hamzah was entirely 'off the radar' of services for so much of his life was an indicator of concern although was not recognised until 2010 partly because nobody had a complete overview about the situation."
The report said: " The usual procedure for routine health care surveillance was undermined by Amanda Hutton's complete withdrawal from every service. The extent to which the younger children were never seen by any health professional after the first birth contact is quite out of the ordinary."
It also said: "Several professionals tried to offer help at different times although none were able to overcome the resistance that was exhibited by both of Hamzah's parents."
The report looked in detail at the domestic violence at the house and how this was treated by police and other agencies.
It said: " The mind-set that prevailed here was that Amanda Hutton had problems but was not considered to be a risk to her children."
When Hutton was classed as at high-risk due to this abuse, her case was mentioned at a multi agency MARAC meeting.
The report said: " The only multi agency discussion which was limited took place at MARAC and this was focused on the risk to Amanda Hutton and not upon her children."
It said: " Not all of the relevant services such as the GP were aware of the discussion at MARAC or the decisions. If they had been there may have been a different approach to the lack of contact with Amanda Hutton and the children.
"The MARAC had only recently been established and for example Children's Social Care Services did not have consistent representation at the time. Other agencies such as education and early childhood services were represented but the people attending the meeting did not communicate information within their own service and did not apparently implement the actions that had been agreed.
" Apart from the MARAC, there were no inter agency meetings or formal discussions although there were discussions that took place over telephone or email or took place within single agencies; the consequence was that individual people and services were always dealing with incomplete information.
"The MARAC discussion was focused on Amanda Hutton as a victim of domestic violence and there was insufficient account of the impact on her capacity to meet the needs of her children."
The report also said: " Overcoming issues such as working in different agencies does require busy people having the capacity to talk with each other as much as doing their own core job.
"The factors are multi-faceted and includes over identification with the needs of Amanda Hutton, a lack of sufficient sceptical enquiry for example in regard to the disappearance of some of the children from health, education and social care systems, a reluctance to engage Amanda Hutton on anything more than a voluntary basis and an inability to identify the significance of the various and cumulative indicators of risk over time."
George Galloway, Respect MP for the area of Bradford where Hutton and her family lived, said: "We are expected to believe from this review that despite numerous inquiries and alerts, from neighbours, the involvement of the police, teachers, social services - a whole multiplicity of agencies - despite the obvious signs from the house, the smell which was overpowering, the state of the other children, that the death of Hamzah Khan could not be predicted.
"Well, what could be predicted, and I did, is that those investigating this deeply sad and troubling death would thoroughly coat themselves in whitewash, which they have done.
"Hamzah's mother is responsible, but he has been failed not just by those who should have been there for him but those who are now attempting to cover it up."
Referring to Prof Frost, Mr Galloway said: "He blames a system failure, as if no human had any involvement in creating, implementing or monitoring the system.
"We need a thorough, independent and urgent inquiry into this catastrophic failure and all of those involved in signing off on this charade removed from any future involvement. It's more than a serious case for concern, it's a serious case for reform."