Years of failed government child-care policies and social workers overwhelmed by red tape and the burden of bureaucracy lie at the heart of the Baby P scandal but ministers obsessed with a tick-box culture who've driven through and imposed the changes are let off the hook in Lord Laming's whitewash which is published today.
At the heart is a government obsessed with the child protection process, leaving the critical outcome, the interest of the child, to take second fiddle and go to the wall.
Confusion over a whole raft of child protection changes, which left social services departments overwhelmed by government imposed bureaucracy, are at the centre of the tragedy in an obsessive drive with that process.
Too many changes in the past few years have led to confusion. Now that's set to lead to just more changes and more confusion. Too often those on the front line and the firing line - the social workers and health workers - are distracted by the changes and chained to their computers, when they need to be able to get out and focus on the child.
The blame game gets into full swing today, spinning away any accountability from children's secretary Ed Balls, who's been careful not to set his sights too hard on local council's child protection systems nor to scapegoat social workers with their managers having to take the rap.
The tired old "doing a difficult job under difficult circumstances" line for social workers is being trotted out, ignoring the fact that when things go wrong, there must be accountability and the buck ultimately stops with Balls and his department.
Millions of pounds have been thrown at useless child protection initiatives which failed to put the interests of the child first, departments are bogged down with paper work, form-filling and unrealistic targets. Social services chiefs can hide behind a smokescreen of targets, performance indicators and meaningless Ofsted reports. All geared to the management of the process.
Sacked director of Haringey children's services, Sharon Shoesmith, who has been demonised as the fall-guy after a damning report into the death, has already accused Balls of acting with "breathtaking recklessness" and sees herself as the scapegoat.
But the remit Balls gave to the Lord Laming review was very tightly controlled to avoid any finger of blame pointing at government ministers. And the children's secretary has refused to publish the Serious Case Review into Baby P which begs the question what have ministers to hide?
At the heart too is the quality and status of social workers and senior managers. The answer from the government? Another 'task force' and Common Purpose-style leadership courses for senior managers and directors.
More mindless changes, more re-organisation will lead to more disruption. It's excessive bureaucracy which is hindering efforts to look after vulnerable children. But the children's secretary can hide behind the whitewash of a report and blame it all on a bunch of social workers and their managers, trotting out the tired old line of 'accountability'.
Laming's review was commissioned by the government after the brutal death of 17-month-old Baby P in the north London borough. But Lord Laming had already called for reforms of child protection with his inquiry into the horrific death of Victoria Climbie in the same borough four years ago. Nothing much happened since then.
Once again ministers can hide behind a mask of smug arrogance and escape any accountability. What is required is a change in culture but woe betide anyone who has the audacity to have a go at them.
Laming's report into the death of Victoria Climbie didn't make much difference to the suffering of innocent children and nor will this, until the government and children's secretary Balls wake up to a few home truths.
A clear failure of years of misguided child protection policies and culture, red tape, form-filling, the overwhelming burden of bureaucracy and a government obsessed with that process not the outcome are at the heart of a systemic problem which led to the shocking death of Baby P.