More children like Ellie Butler, who was battered to death by her father, could die unless action is taken, a coroner has warned.
Ben Butler murdered his six-year-old daughter at their home in Sutton, south London, in 2013, months after a judge said she could be returned to his care.
Butler was jailed for life with a minimum of 23 years for killing Ellie.
Dame Linda Dobbs said there was a risk of further deaths if communication between agencies was not improved.
Ellie had been placed into the care of her grandparents Neal and Linda Gray when she was a baby after Butler was accused of shaking her.
He successfully appealed the decision and Mrs Justice Hogg in the family division of the High Court ruled that Ellie’s parents had been “exonerated” of causing her injuries.
She was returned to their home in Sutton in November 2012, where she was fatally attacked by Butler 11 months later.
Dame Linda ruled at an inquest this month that failings by agencies such as social workers and Sutton Local Safeguarding Children Board did not contribute to Ellie’s death.
But in written documents later seen by the BBC, the coroner added: “In my opinion there is a risk that future deaths could occur unless action is taken.”
In a Section 28 report, Dame Linda said the decision to appoint independent social workers was “unusual” and had “ramifications” for other agencies which “were not properly discussed”.
She added that no agency “appeared to take ownership” for ensuring an assessment of Ellie’s mother’s emotional needs was conducted.
Jennie Gray was jailed in 2016 for three and a half years for child cruelty and attempting to pervert the course of justice.
Dame Linda also criticised the lack of communication between those involved in Ellie’s move back home, and a tendency for decisions to be taken by lawyers rather than the professionals involved.
She urged that all recommendations from a Serious Case Review into Ellie’s death are implemented.
Dame Linda did not criticise Mrs Justice Hogg’s decision to allow Ellie’s parents to look after her.