"MULTIPLE warnings about staff absence and other child protection dangers in Fife were repeatedly overlooked in the months before the murder of Liam Fee."
"Senior figures from Fife Council, NHS Fife, Police Scotland, the Scottish Government and children's charities were all made aware of the long-standing concerns."
"Yet, despite being the potential for `severe consequences` being made abundantly clear, the matter was simply batted back and forth between various panels for more than a year before the two-year-old's death."
"During the murder trial that horrified Scotland, Fife's child protection team manager Karen Pedder admitted Liam had `fallen off the radar` after his social worker went off sick on April 1, 2013."
"Just a few weeks later, on June 26, 2013, the Child Protection Committee discussed an `amber alert for child protection` that had been triggered by a `staff absence`..."
"The amber alert was also discussed by the Fife Chief Officer's Public Safety Group on the same day at the council headquarters in nearby Glenrothes."
"John Myles, the chairman of the CPC, again told the meeting it had been triggered by a `staff absence` and added: `This was a recording issue not an information sharing issue`."
"Ken Greer, chairman of Children in Fife, even warned `that it was important to remember that the cumulative effect of staff absence does impact on service provision`."
"Among those present were Fife Council chief executive Steve Grimmond, Police Scotland commander Garry McEwan and NHS Fife chief executive John Wilson."
"The alert was also flagged up to the Fife Partnership Board on August 28, 2013, when Scottish Government head of resilience Michael Kellet was in attendance."
"At a further meeting of the CPC on October 9, 2013, Fife's nursing director Dr Scott McLean said `that he had spoken to the Lead within Police Scotland and the Social Work lead and our arrangements around Child Protection are deemed safe`."
"However, the alert remained in place until December 2013, just three months before Liam was killed by a blow that ruptured his heart on March 22, 2014."
"In a terrible year for children in Fife, Mikaeel Kular, three, was beaten to death by his mother and his body dumped in woods in Kirkcaldy in January and Madison Horn, two, was murdered by her babysitter in Kelty in April."
"Incredibly, however, the minutes from 2014 show these three tragedies were never even considered by the Child Protection Committee."
"Instead, most of the time was spent discussing the Scottish Government's Girfec - or 'Getting it right for every child' - approach, including the Named Person for every under-18."
"Meanwhile, further evidences shows that yet another expert panel - NHS Fife's Clinical Governance Committee - was aware of child protection problems from at least December 2012."
"In April 2013, the committee members were told: `There is a risk the Child Protection systems and processes are not routinely updated, widely understood, used or adhered to by NHS Fife staff, potentially placing children at risk in Fife`."
"Chillingly, the papers also warned `the consequences of an incident occuring would be severe so the risk remains high`."
"In February 2014, just a few weeks before Liam's murder, Fife's lead child protection nurse revealed the `impact` of red tape created by the Girfec reforms."
"Fiona Lornie said: `Inter-agency Referral Discussions (IRDs) continue to have a significant impact on the workload of the Child Protection Nursing team despite an internal review and changes to processes. Whilst this is an important function of the team it also causes a delay in development of the Child Protection service`."
"Dr Gordon Macdonald, Parliamentary Officer for CARE for Scotland, said social work departments had borne the brunt of council spending cuts in recent years..."
"They have created a huge amount of extra work without resourcing it properly and the danger of making the haystack so big is that you don't catch the needle."