A hospital trust’s response to the death of a baby who was shaken to death has been labeled as ‘seriously inadequate’ by an independent investigation.

A report into the death of 16-month-old Kyle Keen at Walsall Healthcare Trust in 2006, which was published last week, has concluded there was a “significant probability” that the baby’s death could have been avoided if staff at Manor Hospital had referred him to social services.

The report, by Cordis Bright consultancy, said concerns by medical and nursing staff that suspected the baby’s injuries were deliberately inflicted were not listened to.

Kyle died in June 2006 from a brain injury just days after being admitted to the hospital where staff noted bruises.

But despite concerns being raised, a senior consultant took no action and the baby was discharged.

The toddler’s stepfather Tyrone Matthews was later jailed after pleading guilty to manslaughter.

The report also claimed that record keeping at the trust had been poor due to numerous omissions, and criticised the trust for conducting a poor investigation at the time.

The baby’s natural father Robert Keen said he only learned of serious errors in 2012 and has accused the hospital of hiding mistakes in the past.

David Drew, head of the paediatric department at the hospital at the time of Kyle’s death and who saw him in the hours leading up to his death, said: “From day one it was quite clear an opportunity had been missed the previous week and this little boy had suspicious, unexplained bruising.”

Dr Drew claimed he was dismissed by the trust in 2010 for raising concerns about the department.

Trust chief executive Richard Kirby said changes had been made since the incident.

“As the report recognises, we have already made significant improvements in the way we work together across the organisations responsible for services for children in Walsall to improve the services we provide,” he said.

“This did not happen in Kyle’s case and it is right that an apology should be given to Kyle’s father.

“Since these tragic events, we have improved the way we work, and always keep in mind that there is a child or young person at the heart of everything we do.”