The Herald revealed yesterday that a PwC investigation into Child Protection Significant Case Reviews at Scotland's largest health board, NHS Greater Glasgow and Clyde, had shown there was a lack of evidence that learning from the most serious cases was being passed on to frontline NHS staff.
The consultants warned if lessons were not passed on, it could lead to similar incidents in the future.
Anne Houston, chief executive of CHILDREN 1st, said the issue of information not being passed on was a common one following the death of children as a result of abuse or neglect.
"We know that some vulnerable children can and do slip through the net, sometimes with tragic consequences," she said. "It is crucial that lessons are learned from such cases and shared as widely as possible with all professionals involved in the care and protection of children, including health and social services, police and teachers, to prevent such tragedies happening again.
"In every significant case review into a child's death in recent years, common issues have been the failure of professionals to act on information early enough and of agencies to share appropriate information about risks to a child. Often such reviews also show that more could have been done to engage with the family and the community around the child. Sharing information and following up on any concerns such information provides is crucial."
The investigation into NHS Greater Glasgow and Clyde also found there was little evidence that recommended measures after Significant Case Reviews were implemented fully.
NHS Greater Glasgow and Clyde said following the audit, in September last year, it had "further enhanced protocols for cascading learning".