NHS professionals had eight opportunities in just one month to spot that a 17-month-old baby was being seriously abused.
The child, known as Baby P, which lived with its mother, her boyfriend and a lodger in the London borough of Haringey, died in August 2007 after suffering injuries including a fractured spine.
Baby P had been the subject of a multi-agency child protection plan.
Great Ormond Street Hospital trust, which employed a paediatrician who failed to detect clear signs of abuse two days before the baby died, said in a statement: "One of our staff failed to show the vigilance we expect."
The consultant left Great Ormond Street in June and is now subject to restrictions by the General Medical Council.
The consultant saw the baby on 1 August last year at St Ann's Hospital, which is run by Haringey primary care trust, although the paediatricians are employed by Great Ormond Street.
The baby died two days later. An investigation by Great Ormond Street for Haringey council's serious case review concluded that the health professionals should have been able to detect that the baby was being abused as he "had visible symptoms of physical abuse and chronic neglect," at this time.
The serious case review found that agencies including the NHS and the council's social care department had failed to communicate effectively with each other.
The baby was also seen by a consultant at Whittington hospital trust. A spokeswoman told HSJ there were no concerns about the conduct of that paediatrician.
NHS Confederation deputy director of policy Jo Webber said the case highlighted the need to examine the culture and attitudes within health organisations charged with the care of young people.
She said: "We need to look at the way we balance the rights of parents with the protection of children, the attitude we take towards dealing with people who may be evasive or difficult and the kind of training we provide to health and social workers, who are faced with some of the most difficult decisions we make as a society."
The baby had been admitted into hospital twice in the year before he died - each time suffering from head injuries. In the last month before he died, he was seen by health professionals eight times.
But social workers believed the baby's injuries were due to "insufficient supervision" and his own behaviour, which appeared to tally with the mother's claim that he was "clumsy... with a high pain threshold". The child was referred for paediatric assessment to see if there was any medical reason for this behaviour.
What did the NHS do for Baby P?
December 2006: Baby P, then nine months old, hospitalised for four days with head injury and bruising, which the serious case review found were "considered by medical staff to be suggestive of non-accidental injury." Police investigations begin, leading to child protection plans for Baby P and his youngest sibling.
April 2007: Baby P admitted to hospital for two days with head swelling from injury, scratches and bruises to his face and body, a rash on his face and neck and head lice. Discharged to his home.
June 2007: Social worker notices marks on his body that a medical examination concludes are "probably" due to abuse. Arrangements put in place to prevent mother from having unsupervised contact with child.
July 2007: Police inquiry into December and June injuries inconclusive and no charges made.
July - August 2007: Baby P presented to health professionals eight times. Serious case review found that no "major concerns" were identified about his health and well-being.
1 August 2007: Baby P seen by Great Ormond Street paediatrician for a development assessment. She finds he is "unwell and miserable with a possible viral infection and partly healing scalp infection", prescribes medication and arranges for tests and a follow-up appointment.
3 August 2007: Baby P pronounced dead at North Middlesex University Hospital.