The report found safeguarding practices in the lead-up to Finley Boden's death in December 2020 had been "inadequate" and there were "significant shortcomings" in the assessment and planning of his return to the family home.

However, it said the impact of the COVID pandemic had "severely disrupted" the "protective systems and services designed to detect, prevent and respond to maltreatment" at the time.

One of the social workers involved in the case was off work for six weeks due to illness while the assessment was being carried out, during which time no social work visits to the children or parents took place.

A guardian appointed to represent Finley in a family court hearing was also "shielding" during the pandemic, meaning that, even as lockdown restrictions reduced, they were "unable to return to in-person meetings", the review found.

It comes after Finley's parents, Shannon Marsden and Stephen Boden, were found guilty in April last year of his murder in Chesterfield, Derbyshire, on Christmas Day 2020, just weeks after he was returned to their care.

They burnt and beat the infant - leaving him with 130 separate injuries, including multiple bone breaks and fractures.

Finley's injuries included a fractured thigh and broken pelvis, burn marks and 71 bruises. He also had sepsis and endocarditis - an infection of the lining of the heart.

'Unique pressures'

Social workers had earlier removed Finley from his parents as the local authority, Derbyshire County Council, believed he was likely to suffer "significant harm" at home.

However, he was returned to Marsden and Boden's full-time care following a family court order made in October 2020.

A review by the Derby and Derbyshire Safeguarding Children Partnership (DDSCP) stated that, while Finley's parents were responsible for his death, "professional interventions should have protected him".

However, it found the "unfamiliar working environment" during the COVID pandemic had impacted the work of social services at the time.

According to the review, services were severely disrupted and face-to-face contact with families had reduced or ceased, while dependence on parents "self-reporting" had increased.

However, the council acknowledged that, while the pandemic had created "unique" pressures, "more could have been done to 'work' the case and to formulate the final care plan with partners".

"The most significant professional decision for [the child] was that [he]... should live with his parents," the review found.

"Analysis of practice throughout the period of this review suggests, however, that the safeguarding environment in which that decision was made had been incrementally weakened by the decisions, actions, circumstances and events which preceded it."

The review also found a risk assessment by substance misuse experts into Boden's use of cannabis was "not robust".

"In addition, there was no communication between substance misuse services and children's social care," the review found.

It said that all staff in substance misuse services had since attended a "learning event" on the impact of cannabis on parenting and provided "professional curiosity workshops" for staff and enhanced training for safeguarding leads.

Derbyshire County Council's children's services apologised for the "missed opportunities".

The council's executive director for children's services, Carol Cammiss, said: "Despite the significant COVID restrictions placed on our work at the time, we know there were missed opportunities for stronger practice and we apologise for that."

She said the council had acted quickly after Finley's death to "review and strengthen our systems and continue to monitor the way we work with babies and families" and that it accepted the findings and recommendations of the review "and takes full responsibility for its actions in this case".

The Derby and Derbyshire Safeguarding Children Partnership said it accepted the review's recommendations in full and would "take the additional action necessary to further reduce the risk of a repeat of a similar incident".

Independent chair of the Derby and Derbyshire Safeguarding Children Partnerships, Steve Atkinson, said: "I express my condolences, and those of the safeguarding partners, as well as offer a sincere apology to the family that this happened to Finley.

"But I ask them, and you, to remember Finley's parents were responsible for his death, not any practitioner, from any of the caring services.

"The report acknowledges that there were significant mitigating circumstances leading up to Finley's death - the COVID lockdown, the very restricted access, unfamiliar working circumstances and remote meetings, and parental dishonesty.

"However, these are not excuses. More could and should have been done to keep Finley safe."

How was the decision to return Finley made?

In the October 2020 family court hearing, one social worker warned that Finley would be "at risk of suffering from neglect, physical and emotional harm" if Marsden and Boden continued taking illegal drugs or failed to continue making positive changes.

A representative for Derbyshire County Council told the hearing that "all parties" agreed Finley should "transition" back to the care of his parents, but asked for this to be staged over four months and with the need for additional drug testing.

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However, a guardian, employed by the Children and Family Court Advisory and Support Service (Cafcass) - who represented Finley at the near-two-hour hearing - argued that the transition should be faster as the couple had "clearly made and sustained positive changes".

The final decision was made by two magistrates assisted by a legal adviser - who supported the guardian's view that an eight-week transition was a "reasonable and proportionate" length of time.

'Unimaginable cruelty'

During the couple's sentencing at Derby Crown Court in May last year, a judge described the pair as "persuasive and accomplished liars" who inflicted "unimaginable cruelty" on their son.

The judge also said the parents lied about Finley having COVID to prevent anyone from coming to see the baby.

Both were given life sentences, with Shannon Marsden sentenced to a minimum term of 27 years, and Stephen Boden sentenced to a minimum term of 29 years.