As the facts emerged about the death of four-year-old Daniel Pelka, many of us will have reflected that this story sounded sadly familiar.
Daniel lived with his mother and her boyfriend who subjected him to sustained physical abuse.
He suffered 30 separate injuries to his body, was the expected weight of an 18-month-old baby and had been observed with severe bruising, black eyes, and trying to feed himself from school dustbins.
Daniel had appeared on the radar of a number of agencies, social services, health, teachers and police.
All of them, to their great shame, let him down.
Yet, Daniel's story evoked memories of other tragedies - like the death of Baby Peter. He was just 17 months old when he died after sustained abuse.
All of the agencies were given multiple chances to intervene, yet they didn't. Again, they let Peter down.
There was also the case of Victoria Climbie, 8, who died after suffering 128 injuries, despite agencies having a dozen opportunities to intervene. Again, let down.
I'm not sure when in this era of no blame cultures, parental rights, civil liberties and political correctness we strayed off course, but we have.
Nothing in what I have said should be taken to infer that I am one of those who would openly criticise colleagues with the benefit of hindsight and without having experienced the issues at first hand.
I experienced enough silly people doing that to me when I was Chief Officer of Strathclyde Fire & Rescue.
No, my purpose in making these observations is not to criticise front-line professionals undertaking these fine-line assessments, but rather the system and context in which they work.
Despite inquiries, reports, reviews and recommendations, there remain serious failings - failings in learning lessons.
Most social care staff have not even read the outcomes of the above cases. Whether they are too busy, or the organisation does not promote the recommendations, this remains a sad fact.
THE inquiries point to systemic failures in relation to inter agency communications, assessments and decision making, yet the failings remain.
According to the British Association of Social Workers, there is little organisational learning and that which is learnt, remains at the local, rather than the national level.
There have been hundreds of serious and significant case reviews over recent years, yet where is the evidence to support real, meaningful change on the ground?
These are institutional not individual failings.
It will doubtless satisfy some to sack individuals. Yet it is not isolated individuals at fault when a system lets these children down. It is the system at fault and it is the system that must be reviewed.
A national system of inter agency working, with all of the agencies in one room, sharing the same data, talking the same language, dealing with the same problems and risk, in one joined up way.
It is not difficult in a small country like Scotland to make such a unit viable.
This is real community safety, it needs to happen soon.
In Scotland, we have slightly different approaches from the rest of the UK, yet similar problems.
LAST year, the cases of Declan Hainey and Alexis Matheson threw up yet more lessons to be learned, and there are others.
This year, the Scottish Government published proposals to merge Health with Adult Social Care.
I have no objection, in principle, with such a merger but it will be challenging. Combining central and local government services is never easy. The financial pressures on both are almost as acute as the cultural differences.
Both Health and Social Services face significant institutional challenges and both have been heavily criticised in recent months.
The proposed merger will increase pressure on systems now struggling to satisfy public expectation and meet demand.
The distractions of next year's independence referendum will also concentrate political minds on other issues.
As a nation, let's make sure that while the adults might be busy elsewhere, someone is keeping a close eye on the kids.