In essence the inquiry's findings were perhaps eminently predictable: the headline conclusion largely absolves officialdom from immediate blame in relation to the death - "there was little opportunity to prevent the fatal assault on Brandon" - but, on the other hand, "the inquiry revealed gaps and inaccuracies, some caused by pre-existing systems, others by a lack of available resource."
Thus, and without reading the full report, a salient omission discernible from press articles is the lack of any blame attributable to individuals - it's the systems and procedures that are to blame, not any individual person or people.
This follows the pattern of other such inquiries - fundamentally, officials have done nothing wrong, but balance is maintained by including some lesser criticism and thus officialdom and politicians are largely absolved from blame and can seize on the shortcomings to portray themselves as riding to the rescue in relation to implementing improvements.
But this equally predictably leaves many questions unanswered. For example, the Evening Telegraph reports that at a press conference:
Asked if [Mr Wilson] thought the three-week period between “an urgent meeting of child protection partners” on February 28, 2008 and “an urgent case conference” set for March 18, was appropriate given the use of the word urgent, Mr Wilson replied that, “Again I would say they looked at the information and there was ‘nothing at that stage’ to set any alarm bells ringing.So if there were no alarm bells ringing then why were the meetings deemed "urgent"? Ah, perhaps this contradiction was due to the lack of available resources, or whatever.


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