Case changed the system

Alyson Leslie, who proposed a string of recommendations in her inquiry report, said progress already made would, "in some small measure, serve as a memorial to John Smith, who was failed by the very system which existed to protect him".

Known as a Part 8 Review, her report praised all agencies, including Brighton and Hove and West Sussex area child protection committees, for their "unprecedented" response.

Brighton and Hove social care and health directorate, the target for most of the recommendations, received special mention for its "frank acknowledgement" of problems and the commitment shown to address them.

The key changes mean:

Investigations into adopters have been tightened with greater emphasis on distinguishing between reported and evidenced information, with more independent corroboration of applicants' histories
Extra training has been introduced for both investigators and adoption panels
There is now closer scrutiny of applicants' psychological history and training has been provided for GPs
A major review of social work management in Brighton and Hove will bring in new safeguards next April but systems have already been introduced to relieve pressure on staff dealing with more than one serious child protection matter at a time
An extensive training programme for social work staff, health visitors, school nurses and school doctors has begun
Worthing Priority Care Trust is establishing a specialist health visitor post with specific responsibilities for children in care.

Ms Leslie said East Sussex, Brighton and Hove Health Authority and the South Downs NHS Trust had re-examined management and practice to ensure best practice for promoting the welfare of children.

She said: "Systems and procedures alone do not protect children, child protection is the function of effective health and social care practitioners."

Her final recommendation was for another independent review in a year to strengthen public confidence.