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A hospital that treated a toddler weeks before he was beaten to death by his mum should have referred the visit to social services, a serious case review has said.
Staff at Darent Valley Hospital are said to have been "shocked and distraught" when told young Bobby Louch had been murdered.
It happened just three weeks after they had treated him for a broken leg.
The hospital has apologised for not referring the 21-month-old's A&E visit, on December 8, 2008, to child social services teams in Bexley, where he lived with mum Collette Harris.
She has been sentenced to at least 16 years behind bars for punching and kicking him to death on December 29 that year.
Staff at the Dartford hospital were suspicious of the child's injuries but could find no evidence they were caused by anything other than an accident and did not refer the incident on, according to a report from Bexley's local safeguarding children board.
But although the hospital has now been advised to refer any unexplained serious child injuries to social services, the serious case review has concluded the tragedy was "not foreseeable".
For the full story see this week's Dartford Messenger.