Case review states that the death of Kelty toddler Madison Horn 'could not have been anticipated'

She was brutally murdered in her own home by Kevin Park, the former boyfriend of the two-year-old's mother, while he was babysitting in April 2014.

Fife's Child Protection Committee's independent chairman, Alan Small, said: “The review has concluded that Madison’s death could not have been anticipated.

"There was no evidence to suggest that any agency was aware of any concerns about her well-being and neither she, nor her mother, were known to social work services.

“The report published today also states that certain aspects of this case could have been managed more effectively and identifies some learning points."

Madison suffered 65 separate injuries and Park was jailed for life and told he must serve at least 22 years for her "wicked" murder.

After the verdict in November 2014, Fife Chief Officers’ Public Safety Group decided an independent significant case review would be held.

The findings were published today and Mr Small commented: “The tragic death of Madison shocked and saddened all those who knew her.

"She was well looked after by her mother and her family. They have all been devastated by her loss in such brutal circumstances.

“The person responsible for Madison’s death, Kevin Park, is currently serving life imprisonment for her murder.

“We are responsible for working with families and communities to protect children and provide them with a safe, nurturing environment. Nothing is more important.

"In the circumstances where a child has died it is right that we reflect on what happened to see whether there is any scope for improvement.”

The key findings of the review were:

- Madison’s death could not have been anticipated

- There were no agency concerns regarding her well-being at the time

- Neither Madison nor her mother were known to social work services

- NHS Fife health records described Madison as being a well-adjusted child who was meeting all her developmental milestones

- All agencies involved fully accept the report’s findings and that there were things they can do better, particularly around the sharing and management of information.

Park, who was 27 at the time, was sentenced by judge Michael O'Grady QC, who told him: “In reality, no sentence I can impose can truly reflect the sheer awfulness of what you have done.”

Park battered Madison's head off a wall at least twice, punched and stamped on her and prosecutors believe he may have also used a broken pool cue in the violent and sustained attack.

He also grabbed or pinched the ears of the little girl, who weighed 13.3 kilos and was 90.5cm tall, causing horrific bruising.

Her skull was fractured and she suffered internal bleeding and tearing to her liver.

The significant case review was commissioned by Fife Chief Officers’ Public Safety Group following Madison’s death and led by Safaa Baxter.

Mr Small said: “Ms Baxter has conducted interviews with all relevant staff from the agencies involved in this case and scrutinised files, policies and procedures.

"What is being published today is an independent, thorough and comprehensive account of her findings and it’s important to stress that we are being as open and transparent as we can possibly be."

He continued: “One of the learning points relates to the management and sharing of information. There are robust information sharing procedures to help us share and manage information across agencies in Fife.

"The review found that in this instance more could have been done to ensure that these procedures were fully understood by all involved and that the information available was considered and fully analysed in respect of the potential risk posed by Kevin Park.

“In addition the report highlighted as a learning point continuity of the management of offenders for the agencies involved. We are committed to improving this aspect of work.

“We are also reassured that recommendations in the report around tracking the movements of offenders are being taken forward by the Scottish Government and appropriate partners.

“Finally, we publish and publicise the results of significant case reviews to promote learning as widely as possible across all appropriate agencies.

"We fully accept the report’s findings and we are taking every opportunity to improve and strengthen our practices.”