Two-year-old Lola James was attacked by her stepfather Kyle Bevan in her home in Haverfordwest, Pembrokeshire, on 17 July 2020 and she died four days later.

The 31-year-old killer was given a life sentence with a minimum jail term of 28 years last April.

Swansea Crown Court heard evidence that Lola had suffered 101 separate injuries to her body, including a "catastrophic" brain injury.

Bevan, from Aberystwyth, claimed Lola had fallen down the stairs after the family dog - an American bulldog - pushed her.

Her mother, Sinead James, was sentenced to six years for causing or allowing the death of a child.

A child practice review, commissioned by Mid and West Wales Safeguarding Children Board, has now published its findings, including that an assessment of Lola's needs was "not properly undertaken" prior to her death.

Child practice reviews are carried out when a child dies or sustains serious injury while not on the child protection register or a "looked-after child" during the six months before the event.

'Lacking in detail'

The review found that an assessment of Lola (referred to in the report as child A) carried out by Pembrokeshire County Council's children's services on 10 February 2020 was "lacking in detail and analysis".

The report also found the assessment had not been completed by the named social worker, who was absent from work at the time.

The assessment was in fact created on 18 March 2020 and closed on 30 March 2020 by their manager.

The rationale given by the manager to the review team was they were "closing down assessments for staff who were on sick leave in order to manage the team's workload".

"The consequence of what happened in this case is that an assessment of child A's needs was not properly undertaken by children's services, as required," the review concluded.

The review found "the service was overstretched and morale was low", but notes the situation was "far more positive" as of June 2024.

'Missed opportunities'

The review also raised "a number of missed opportunities by the health visiting service".

This includes the conclusion that the health visitor "could and should have made arrangements for a home visit" after a telephone call with Sinead James on 8 June 2020.

James failed to agree to any home visits in the five-month period between 15 February 2020 and 16 July 2020.

"In future cases, far more probing and challenge is needed by health visitors," the review found.

The local authority's immediate internal review into Lola's death "did not identify a number of issues regarding the assessment process".

The review also concluded it was "disappointing" that information-sharing between multiple agencies continued to feature as a factor in reports like this one.

'Deaths avoided in the future'

Emma Sutton KC, who authored the independent report, told Sky News she hopes there will be "positive changes in the very near future".

"I was really clear in this report that Lola wasn't lost and I very much hope that the family feel reassured that if something's going to come out of this tragic circumstance that there will be deaths avoided in the future," she said.

"It's very clear that the rapid review in this case did not identify a number of the matters that I was able to subsequently identify and if you can't get those matters correct at the outset, the whole process thereafter, how can you have confidence in that?

"The local authority have been very clear that their policy for rapid reviews is going to change and that there'll be an ability right at the outset to identify what the key issues are."

Rocio Cifuentes, the children's commissioner for Wales said there were "national learning points from this report" and that there were "serious questions for the Welsh government".

The NSPCC has also said child protection must be made a "national priority" and there needs to be more detail from the Welsh government on "timescales, activity and progress".

A Welsh government spokesperson said it will "carefully consider the learning identified" by the review and was developing a new framework to promote best practice.

'Considerable progress made'

Councillor Tessa Hodgson, Pembrokeshire County Council's cabinet member for social care and safeguarding, said the local authority "takes extremely seriously its duties within the safeguarding arena".

She said: "We had developed an action plan to deal with the issues the review has raised for us, and we have made considerable progress against that plan already."

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In a joint statement, Pembrokeshire County Council, Hywel Dda Healthboard and Dyfed-Powys Police said they "wished to convey their sincerest condolences" to Lola's family and all those affected by her murder.