Injuries on a five-year-old boy - who was murdered by his mother, stepfather and stepbrother - were not shared by doctors with others that could have taken action to protect him, a review has found.
It found what it said may be "systemic" issues with safeguarding children, including a failure by health practitioners to report injuries Logan Mwangi suffered months before his death.
The little boy was fatally attacked in his home in Llansantffraid, Sarn, Bridgend, in South Wales, before his body was dumped in the nearby River Ogmore in July last year.
His mother, Angharad Williamson, 31, stepfather John Cole, 40, and stepbrother Craig Mulligan, 14, were all convicted of murder and received life sentences following a trial at Cardiff Crown Court earlier this year.
The trial heard the child, also known as Logan Williamson, had 56 external injuries when his body was discovered.
Weeks before he died, he suffered a broken collarbone but was not taken for treatment.
The report by Cwm Taf Morgannwg Safeguarding Board, published today, also highlighted how the COVID-19 pandemic limited the family's contact with agencies and impacted on the ability to provide "optimum child protection processes".
"As a result of this extended child practice review, key learning has been identified," the report stated.
"The review panel believes that these issues may be systemic, and not isolated instances of individual error or poor practice."
In August 2020, Williamson took Logan to his local accident and emergency unit with an injury to his arm, bruises to his right cheek and a fractured upper arm - and concerns were raised in relation to the delay.
However, social services and police "agreed that the threshold to undertake child protection inquiries had not been met at that stage, on the basis that there was limited medical information", the report said.
Cole had previous convictions including assault on a child, possession of an offensive weapon, theft and illegal drug possession, and had served a prison sentence for burglary.
Police checked these and it was "agreed at that time he was not an appropriate person to solely care" for Logan or Mulligan.
Officers attended the hospital as well as the family home, where they were told Logan's injuries were due to him falling down the stairs.
A further health assessment by a paediatric doctor found "wider bruising and injuries" on Logan, with 31 images taken of these.
Records document that he had a blue mark above his genitalia, two bruises to his ankle, two bruises to his forehead, bruising to the top of both ears, bruising behind one ear, bruises to both cheeks, a carpet bruise to his chin, bruising to his left arm and bruising around his broken shoulder.
The report said there was "no evidence that information about these injuries was shared with agencies outside of the health board".
Williamson claimed Logan - referred to as "Child T" in the report - would bang his head, pinch himself and said the mark to his ears was from wearing a COVID mask. No explanation was given to the mark above his genitalia.
"Several of the injuries, even in isolation, should have triggered a referral," the report said.
"If the injuries were considered by health professionals to be non-accidental there should have been clear considerations to the number of injuries and site on the body, parental supervision being afforded to Child T and if wider agencies' support was required.
"This again should have triggered a child protection referral."
The report also detailed how Cole was reportedly a former member of the National Front and would subject Logan - whose father is of British and Kenyan heritage - to racially derogatory remarks.
The report made 10 local recommendations and five national recommendations, including urging Cwm Taf Morgannwg Health Board to commission an independent review into its practice and management of identifying and investigating non-accidental injuries in children.
Nationally, it suggested the Welsh government consider an annual campaign to raise public awareness on how to report safeguarding concerns.
Paul Mee, chair of the Cwm Taf Morgannwg Safeguarding Board, apologised for failings, saying "agencies could and should have acted differently".
"For these failures, we take full responsibility and apologise," he said, pledging to "fully implement the recommendations made in this review and in doing so improve our safeguarding practice to prevent this from happening again".
Lessons must be learned from the review, the Welsh government's deputy minister for social services said, as she too apologised for the tragedy.
Julie Morgan said: "I want to repeat how sorry I am to Logan's father and reiterate my commitment to improve services to ensure vulnerable children are protected."