Kennedy McFarlane died in May last year

The independent inquiry, which was carried out by consultant paediatrician Dr Helen Hammond, said the child's life could have been saved if Dumfries and Galloway Council implemented its full child protection procedures.

But it refused to blame any one individual or agency for her death.

In her report Dr Hammond said: ""I do not believe that anyone could have predicted the sudden and violent death which occurred on May 17 (2000).

"However a number of opportunities to identify the extent of the risks to Kennedy and for effective intervention had arisen as the case unfolded.

Dr Hammond highlighted serious eye injuries sustained by the girl in March 2000 and her referral the following month with drug ingestion as warning signs.

'Effective communication'

She added: "I would have expected experienced professionals in both health and social services to have acted differently."

She also said that a lack of "effective communication" between health and social work officials meant that "a formal child protection investigation had not been triggered".

"No one had put all the pieces of the puzzle together creating a total picture of escalating harm within the context of a family in need," she said.

Thomas Duncan was sentenced to life in prison

In her report, Dr Hammond said that a joint investigation by health and social work would have produced sufficient evidence to convince a sheriff of the need to protect her.

She added: "There would have been enough evidence of continuing risk of significant harm to prevent her return to the maternal home.

"It is therefore my conclusion that although on May 17 her violent death could not have been accurately predicted it could have been prevented."

Dumfries and Galloway Council's Director of Social Work, Keith Makin, said the report's recommendations had been taken on board.

"We are at the point now where we are confident that our child protection services are as protective as they can be," he said.

Staff disciplined

"No child protection system is 100% protective as they rely at some point on the judgment of members of staff."

He said that a practitioner and management staff were being disciplined as a result of the inquiry but refused to name them or confirm the numbers involved.

He said one person had been moved to a post where they were not making "operation decisions" and confirmed that the decision had been taken at a "fairly senior management level".

A combined statement from the council, Dumfries and Galloway Acute NHS Trust and the local child protection committee said all agencies accepted the recommendations of the inquiry.