Health officials and social services have been criticised for failures before a 13-week-old baby was murdered by her mum's partner.

A serious case review was launched to identify what went wrong after the young victim suffered 41 separate injuries before her death.

It is understood to be the case of Millie-Rose Burdett, from Rickmansworth, who died in January 2019.

Davey Everson, 23, is currently serving a minimum sentence of 18 years for her murder, while his girlfriend and Millie-Rose’s mother Kirsty Burdett, 25, was jailed for six years for causing or allowing the death of her daughter.

St Albans Crown Court heard Millie-Rose suffered multiple fractures, bruising, and bleeding on the brain. Everson also violently shook Millie-Rose and threw her before she eventually died in a coma.

Read more: Couple jailed over Rickmansworth baby death

Watford Observer: Davey Everson. Credit: Herts PoliceDavey Everson. Credit: Herts Police

The Hertfordshire Safeguarding Children Partnership subsequently agreed to a serious case review, which has now been published.

It found the baby, referred to as ‘Child N’ in the report, would have “benefitted from a more collaborative child-centred approach” and that multi-agency plans were “static” and not updated when concerns arose.

It also found the family were known to social services before and after the baby was born and that mental health concerns had been raised about the baby’s mother.

A multi-agency response to bruising spotted while she was still alive was “absent”, demonstrating the need for practitioners to “fully understand the significance” of bruising to children so young.

Further concerns about domestic abuse and how little the baby weighed were also highlighted as agencies were criticised for the “lack of formal child protection procedures”.

Watford Observer: Kirsty Burdett. Credit: Hertfordshire ConstabularyKirsty Burdett. Credit: Hertfordshire Constabulary

The report offered six recommendations and said “considerable progress” has already been made.

These included understanding more about the significance of bruising and the need for action, making referral pathways “clearer” and more “timely”, and identifying the most “concerning” expectant families.

Jo Fisher, chairman of the Hertfordshire Safeguarding Children Partnership, said: “On behalf of the partnership, I would like to pass on my profound sympathy to those who loved or cared for Child N and who have lost her from their lives forever.

“She was a defenceless baby when she was murdered at just three-months-old by her mother’s partner, and while his conviction for murder, along with the conviction of her mother for allowing the death, was welcome, it is important that we reflect on whether more could have been done to keep this child safe.

“This independent review has looked in detail at the steps health care providers, social services and the police took to try and protect Child N before and after her birth, in order to identify how we can improve the way we work, individually and collectively, to help protect other children at risk.

“All the partners involved have fully co-operated with the review and I’m confident the recommendations are already being implemented, and that we will have even stronger protections for vulnerable children as a result.”