A seven-year-old Birmingham girl starved to death after a catalogue of "missed opportunities" by social services and other professionals, a serious case review has found.

The report, by the Birmingham Safeguarding Children Board (BSCB), comes more than two years after Khyra Ishaq died at her Handsworth home.

Following months of starvation and cruelty at the hands of her mother and stepfather, Khyra died in May 2008 when her body succumbed to an infection.

But the report found that her death could have been prevented, and occurred after the authorities "lost sight" of her.

Hilary Thompson, chairwoman of the BSCB, said: "The serious case review concludes that although the scale of the abuse inflicted would have been hard to predict, Khyra's death was preventable.

"The report identifies missed opportunities, highlighting that better assessment and information-sharing by key organisations could have resulted in a different outcome."

The 180-page report found that, despite concerns being raised by members of the public and school staff about Khyra's welfare as far back as March 2006, information was not acted upon and safeguarding procedures were not properly followed.

It said: "There were a number of early missed opportunities for intervention by professionals.

"Three incidents during March 2006 were not progressed, either by failures of paperwork to reach the correct departments, failure to follow safeguarding procedures, or to conduct thorough checks prior to case closure, resulting in any knowledge and intervention remaining purely single agency at that stage."

The review, which began in May 2008, concluded: "Had there been better assessments and effective inter-agency communication over a period of time it (Khyra's death) could have been prevented."

A complaint of harassment by Khyra's mother, Angela Gordon, against a social worker who visited their Handsworth home in February 2008 "generated a reluctance" to complete an assessment, the report found.

It said: "The complaint by the mother... appeared to impact upon the Children's Social Care manager and practitioner.

"This action appears to have generated a reluctance to follow through on plans with a partner agency to effectively pursue assessment procedures, for fear of wider repercussions within the complaints process."

The report continued: "Whilst a number of agencies and individuals sought to deliver effective services to the child... there were others who lost sight of the child and focused instead upon the rights of the adults, the adults' behaviours and the potential impact for themselves as professionals."

In March, Mr Justice Roderick Evans sentenced Khyra's mother Angela Gordon, 35, to 15 years and jailed her former partner, Junaid Abuhamza, 31, indefinitely for the public's protection, with a minimum term of seven-and-a-half years.

The pair were cleared of murder during a trial at Birmingham Crown Court but convicted of manslaughter.

During the trial it emerged that Khyra had been removed from school in December 2007 and subjected to a punishment regime which included standing outside in the cold for long periods, having cold water poured over her and being beaten with a bamboo cane.

She and five other children in the care of Gordon and Abuhamza at their Handsworth home were deprived of food and prevented from entering the fully-stocked kitchen by a bolt fixed out of their reach on the door.

Education Secretary Michael Gove said that Khyra's death should have been prevented. He said: "It is beyond anyone's comprehension that a child could die under such tragic circumstances.

"It is extremely difficult to prevent random and isolated incidents of violence against children, but the tragedy is that Khyra Ishaq endured a painful abuse over many months and eventually died, and this could and should have been prevented.

"Today's serious case review confirms that all the agencies in Birmingham failed to protect this vulnerable child."

Mr Gove said: "We respect the right of parents to educate their children at home and most do a very good job, some of them picking up the pieces where children have had problems at school.

"We strongly encourage local authorities to develop a positive relationship with their home-educating community.

"We note the views of the Birmingham LCSB about the law as it applies to home-educated children and we are aware of the very strong views held by local authorities and by home-educating parents on this matter.

"Clearly lessons need to be learned by the tragic events in this case, and I will consider the letter I expect to receive from Birmingham shortly, to see what changes need to be made to the existing arrangements, and reply in due course."

The report made 18 recommendations for specific action across Birmingham City Council, the city's primary care trusts, West Midlands Police, the Birmingham Children's Trust and the Safeguarding Board.

A further 53 areas for improvement were identified.

Twelve of the recommendations relate either directly or jointly to Birmingham's children's services. The council said 10 of the recommendations had already been "acted upon" and three members of staff who had "significant involvement" with Khyra had been subjected to disciplinary procedures.

Tony Howell, strategic director for children, young people and families, would not comment on the nature of the disciplinary action.

Speaking after the report was handed to reporters, he said: "I know that everyone involved with Khyra and her family in my department has been deeply affected by her death.

"As professionals, we need to make the changes necessary to prevent such tragedies in the future.

"For our part we have undergone a major review of children's social care, strengthened our management team, increased capacity on the front line and are in the process of re-modelling our workforce."

He added: "We will continue to do whatever it takes to ensure children in this city are safe from those who would do them harm."

Les Lawrence, Birmingham City Council cabinet member for children, young people and families, said: "We realise that none of the improvements we and other agencies have put in place can bring Khyra back.

"For that we are profoundly sorry. Today's publication of the serious case review clearly highlights the opportunities missed by a number of agencies to intervene in the abuse being inflicted on Khyra by the people she trusted to look after her.

"Today, as we remember Khyra Ishaq's life, we re-affirm our commitment to create a children's social care service that better protects our young people from those who would harm them.

"Let this be Khyra's legacy."

Mr Howell, who will retire in January, would not comment on whether any social workers had been sacked as a result of the case.

When questioned repeatedly about the disciplinary measures taken against the three staff members who were closely involved with Khyra, he said that all three were removed from frontline services directly after her death but would not reveal the outcome of the disciplinary action, saying that it was "a personal issue".

A council spokesman said it would be in breach of employment legislation to comment on internal disciplinary action.

Khalid Mahmood, Labour MP for Birmingham, Perry Barr, said: "I am glad that the report has been published in full, but in all honesty, there is nothing new in it.

"We all know what the systemic failures were, all this does is point them out.

"It shows that there was no real support for the people that work at the coal face, the hard-working social workers.

"All Birmingham City Council does is try to spin its way out of it.

"Really, the failures are in management. Removing three social workers from their position is not the way to deal with it. The way to deal with it is putting resources on to the front line."

He added: "I don't know how many times we have to recreate the failures before this authority does something about it."

> MORE : Recommendations by the Birmingham Safeguarding Children Board, following Khyra Ishaq's death