Jean Herbison, lead clinician for child protection with Greater Glasgow NHS Board, identifies "buck passing" within organisations and a lack of robust systems.
Dr Herbison's report was commissioned by Highland Child Protection Committee, into the circumstances of the five-year-old Inverness girl who was killed by her father. Danielle was lost to the school system after being withdrawn from class by her mother. The school was told the family was moving to England.
The report includes evidence from Highland Council's education department that Danielle's primary school did not have access to relevant health records relating to Danielle and had not been made aware of the dangers in the mother's background.
Dr Herbison proposes an inter-agency file for each child - "the one file child".
The Scottish Executive has since decided to issue every child entering primary 1 with a unique ID number which should help keep a check on youngsters when they transfer between schools.
Peter Peacock, Education Minister, responded to Dr Herbison's report with a commitment that child protection inspectors would now assess the action taken by all the agencies involved.