Baby Chantelle Pilkington death: Agencies criticised
Health care professionals in Essex have been criticised for a "lack over communication" over the care of a baby who died from head injuries.
Eight-week-old Chantelle Pilkington died in hospital four days after being found "pale and listless" at a house in Shoebury, Essex, in August 2009.
A safeguarding children investigation found concerns surrounding the care of the baby were not shared among experts.
But the inquiry found the tragedy could not have been avoided.
"There was no one significant event or action by any agency which, if done differently, would have changed the sad tragedy," the report said.
The Southend Local Safeguarding Children Board (LSCB) found decisions made about the care of Chantelle - who was identified in the report as Baby Kathy - were based on "limited information" and "poor or incomplete assessments".
It said doctors, health visitors, social workers and the school of Chantelle's teenage mother had not properly identified "risk factors".
"All professionals could have been more proactive in both seeking and giving communication," the report said.
"What was missing was the use of the forums and mechanisms within which this information could be shared."
The report found "staffing, workload and management difficulties" arose at a time of "re-organisation and restructuring" within the some of the agencies.
It said the "current economic situation" was likely to increase "tensions as further efficiencies are sought".
The report noted professionals who did work with the family were "frequently challenged by aggressive behaviour and resistance".
Chantelle's father, Tom Smith was acquitted of killing Chantelle after juries failed to returns verdicts in two separate trials.
Mr Smith was 26 when the second jury was discharged in May.
After being cleared, Mr Smith, of Hilton Avenue, Aberdeen, spoke of his "two-and-a-half years of hell" in trying to clear his name.
He said he felt it had stopped him grieving properly for his daughter.