According to the report, “no professional tried significantly hard to talk to him,” despite warning signs.
Magdalena Luczak, 27, and Mariusz Krezolek, 34, were given life sentences by Birmingham Crown Court in July for the murder of the boy, who had been subjected to months of abuse.
The case caused an uproar in the UK, after it emerged that the victim had been progressively starved and regularly beaten before he finally succumbed in March 2012.
A severe blow to the head from Krezolek was the decisive piece of abuse, after which the child was left in a tiny room without light for over 24 hours.
Teachers, social workers and police were all criticised in the so-called serious case review.
The Little Heath primary school in Coventry, central England, is accused of failing to act in response to a series of injuries to the boy in the four months leading up to his death.
Teachers had noticed the hungry boy taking half-eaten food from dustbins, but accepted the parents' claims that he had an eating problem.
Meanwhile, a paediatrician is accused of failing to spot that child abuse was the key reason for the boy's dramatic loss of weight in the months leading to his death.
Furthermore, a midwife who had grave concerns about the four-year-old and his siblings was convinced by a social worker not to refer the case to the children’s services at Coventry City Council.
Martin Reeves, chief executive of Coventry City Council, has told the BBC that Coventry “needs to stand up and take responsibility individually and collectively for missed opportunities to have protected Daniel better.”
He added that “we can never say that a situation like this will never occur again but we must be able to say that the same mistakes… mustn't be replicated.” (nh)