Ofsted and council staff are criticised for failing to properly investigate "obvious pointers" about the behaviour of Paul Wilson, a nursery worker jailed for raping a toddler.
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The serious case review into the crimes of nursery worker Paul Wilson criticised Birmingham city council and Ofsted inspectors for failing to investigate concerns about his behaviour and his so-called "special relationship" with the toddler he was abusing.
Wilson, then aged 21, was jailed for life in 2011 after raping a toddler at Little Stars nursery in Nechells, Birmingham. He used a mobile phone to film two separate attacks on the girl.
A review into the circumstances surrounding the abuse, carried out by Birmingham's safeguarding children board, said a lack of rigour and depth in inspection processes had "supported" Wilson's offences.
Among other failings and weaknesses identified by the report was a lack of supervision, poor management within the nursery, and its layout. As well as making eight key recommendations, the review found that the local authority did not communicate with relevant agencies and investigate initial child protection concerns.
Wilson, of Newbold Croft, Nechells, was ordered to serve at least 15 years for the "chilling, vile and depraved" offences committed at the nursery, and the online abuse of more than 20 young girls.
The review found weak safeguarding practice within the nursery helped to create an environment where factors which might have deterred the perpetrator from abusing the child were missing.
Commenting after the publication of the serious case review, the chair of the safeguarding children board, Jane Held, said that responsibility for the abuse lies with the perpetrator, who she described as "clever, duplicitous and manipulative".
She added: "In this case there were unfortunately a number of weaknesses in the way that nursery was run and a number of opportunities to intervene earlier and prevent the continuation of abuse which were missed."
Ms Held pointed to three key lessons from the review: that those looking after children ensure there are strong, clear practices and systems to minimise the risk of abuse; that children are asked about their experience and listened to; and that every single person with responsibility for a child is charged with safeguarding the children in their care.
Watch the original 2011 report from Paul Wilson's trial
07 January 2011
07 June 2011
06 January 2011