The damning conclusions reached in the Hannah Windsor inquiry echo similar findings in other recent Serious Case Reviews of troubled Wirral youngsters.
The review published on Friday surrounding the 2012 murder of Hannah found the extent of her vulnerability "was not understood by professionals working with her.”
It says the many agencies involved had failed to communicate effectively with each other - a finding that has been reached before in at least three case reviews.
Seventeen-year-old Hannah suffered a horrific death last May after being tied to a tree and brutally tortured by her boyfriend Adam Lewis.
The 83-page report, which is anonymised - referring to Hannah as "Child G" - contains 111 separate recommendations for changes to procedures, training and issuing extra guidance to staff.
It found that although her murder could not reasonably have been foreseen, service provision by the professional agencies that were supposed to look after her was “diffuse and lacked co-ordination”
The review charts how Hannah had a difficult childhood and discloses that over the years, the youngster had contact with a large number of agencies and organisations.
Representatives of health, education, social care, police, youth offending and housing services were all involved.
Surprisingly, no multi‐agency “holistic” assessment of her needs, characteristics and behaviour ever took place.
No assessment took account of her developmental progress and the relationship she had with her family or their capacity to care for her.
Information contained in key records was not adequately appraised and no child protection plan was ever formulated.
The report concludes that the many recommendations for improvement are already being put in place.
However, in 2011 a Serious Case Review of circumstances surrounding “Children A,B,C & D” also found there were “several areas for learning” identified.
The report states: “The failings to safeguard and promote the welfare of these children were not located within just one agency.
“Lack of assessment meant that throughout the period of review, interventions were reactive with too great an emphasis on practical support.
“Apart from the initial assessment undertaken very early in this four-year time frame, no other assessments took place during this period either in relation to the needs of the children or the parenting capacities of the adults.
“Yet there was significant evidence that these children were experiencing neglect and growing up in situations of domestic violence.”
In 2009, a review involving “Child CF” found the overarching issue was that agencies "failed to recognise" the extent of parental mental health problems and to devise more appropriate interventions when it should have been clear that the family support measures being offered were not working.
“There is criticism about the quality of assessments undertaken by various agencies including the mental health assessment and the core assessment.”
In 2008, an inquiry involving “Child JLS” found early multi-agency assessments with regard to the child and his family were “not of sufficient depth and detailed analysis to determine the most appropriate and effective forms of intervention.
“There was very little indication of agencies working together on a multi-agency basis and there were some significant deficiencies with regard to information sharing between agencies.”
And an investigation following the death of "Child JC" in 2004 found there was no evidence that care planning for siblings followed agreed protocols.
This led to key parties being excluded from what became a single agency plan from the local authority’s social service department.
In what is now sounding like a very familiar phrase, the report says: "There was poor inter-agency sharing of information and key parties did not fully understand their role.
"Communication was poor as there was no bringing together of key professionals to agree the care plan."