A baby girl was let down by a series of blunders in the investigation into her sudden and unexpected death, a High Court judge ruled yesterday.
The truth about the tragic end of 13-month-old Poppi Worthington's life may never be known, according to evidence made public for the first time.
Senior detectives thought a pathologist "may have jumped to conclusions" when she raised suspicions about how she had died in December, 2012.
But they decided not to investigate until the full post-mortem report was ready - which was not finished until the following summer.
By that time, her body had been released by a coroner, and buried without a proper criminal inquiry having taken place.
Mr Justice Peter Jackson criticised Cumbria Police and county council, saying no 'real' investigation was carried out for nine months after she died.
In October 2014 an inquest lasting seven minutes ruled the cause of death as unascertained.
A family court has ruled that findings in the case can now be made public. They identified a host of police errors, such as not preserving items - including Poppi's last nappy, and a bloodied sheet from a stretcher - for forensic checks.
Senior investigating officers failed to visit the family home and no witness statements were taken until September 2013.
The county council failed to follow national and local guidelines following the death of such a young child.
Her parents home was not examined, her last nappy was lost, and accounts of Poppi's final hours were not checked, according to the newly-released documents.
Her father Paul, 47, watched pornography on his laptop in bed in the hours before she died. Her mum, who cannot be named, was downstairs at the time.
He used his laptop to gamble on sport, and watch pornography, which he described as "involving adults", before falling asleep.
Woken in the early hours by a scream or a cry from Poppi, he found her sitting in the corner of her cot. She was "rigid and stiff" and he thought she may have had a bad dream, he said.
He picked her up and cuddled her before he took her to his room. At 5.56am on December 12, 2012, Poppi's mother called 999 while her father attempted to perform CPR on their child.
An ambulance arrived at 6.05am and a paramedic described Poppi as being "very pale, waxy and obviously not breathing".
She was pronounced dead at 7.07am after passing blood, which her father blamed on her 'being constipated for several days'.
Her parents were arrested in August 2013. Her father was questioned on suspicion of sexually assaulting her - an allegation he denies.
A host of failings by police were identified by High Court judge Mr Justice Peter Jackson as part of the care proceedings in relation to other children in the family. He noted: "Due to the extreme delay in that process, there was no real investigation into P's (Poppi) death for nine months.
"Such minimal investigation as thereafter took place was inevitably affected by the delay and by actions not taken at an earlier stage."
His report noted serious errors, but said evidence from an unnamed detective inspector - who led the investigation from the outset - was "driven with evident reluctance to accept a number of failings in the inquiry".
Details emerged ahead of a review of medical evidence which began in Liverpool yesterday. The case raised a serious concerns after some of the details of Poppi's death were withheld at her inquest.
But a family court ruled "as much information as possible" should be placed in the public domain after The Children's Guardian argued that revealing some information to the media could harm the interests of Poppi's siblings. Both parents denied causing any harm to their daughter.
Mr Worthington was informally interviewed by police in 1995 over his association with someone who may have committed offences against children. In 2003 he was the subject of an unrelated allegation which was later retracted.
Following the family court judgment, Cumbria Police confirmed in March this year that no charges would be brought against anyone over Poppi's death. Cumbria county council said last night they were working on improving children's services in light of the case.