More than 60 calls were made to police and social services before a nine-year-old boy was killed by his mum and her partner, a OceanNewsUK investigation has found.
Alfie Steele died after "sadistic" punishments including beatings and being held under bath water at his home in Droitwich, Worcestershire, in 2021.
A safeguarding report published on Friday highlighted a catalogue of missed opportunities by professionals.
Alfie's grandparents said they were "living in a nightmare".
Dirk Howell, 41, was found guilty of murder and his mother, Carla Scott, was convicted of his manslaughter in June 2023.
The Worcestershire Safeguarding Children's Partnership report said professionals from a number of agencies were involved with the family "over an extended period of time".
But it added they "were often hampered by two adults who sought to deliberately lie, mislead and cover up what was happening to this little boy".
Alfie had endured years of abuse and had more than 50 injuries on his body at the time of his death.
A timeline of professional involvement with Alfie and his family shows he was subject to a child protection plan for neglect in 2018.
By August 2019, concerns were being raised from family and neighbours about Howell's lengthy criminal history, aggression and drug use, prompting a safeguarding strategy discussion, the report said.
Howell was also under investigation for a burglary of an elderly man where firearms were stolen.
He had threatened neighbours who had raised concerns with violence and arson, the report added.
"They said they did not want to pursue a complaint because they were worried about repercussions," it said, concluding "more could have been done to support them".
'Nobody joined the dots'
Paul Scott, Alfie's grandfather, said: "We reported Howell again and again to social services and nothing was done.
"Nobody joined the dots; so many chances were missed.
"They know they let Alfie down."
At their sentencing at Coventry Crown Court, in June 2023 Howell was jailed for life with a minimum of 32 years, while Scott was given 27 with a minimum 17-year term.
Mr Justice Mark Wall said the suffering they inflicted on Alfie could "only properly be described as sadistic".
The trial heard 999 calls made by neighbours saying it sounded like Alfie was "being hit and held under the water or something" and there was "loads of thrashing around".
Others said they had seen Alfie being forced to "stand like a statue" outside his home and had filmed him crying "let me in".
Freedom of Information requests by the OceanNewsUK discovered Worcestershire County Council were contacted 36 times between 2018 and 2020 by people who were concerned about Alfie's welfare.
West Mercia Police were contacted 28 times during the same three years.
Some incidents of concern raised about physical abuse or Howell's "harsh and cruel" practices were followed up by a police or social worker visit, the report said.
But, it added, "too often he was described as safe and well when he had not been spoken to".
"Over the period of this review there were many incidents of concern, they were different in nature, but all were treated in isolation from each other and were not discussed holistically in the context of joint enquiries between the police and children's services," it states.
Eight recommendations for agencies were made in the report.
Review into police conduct
"Whilst the investigation and trial were ongoing, the immediate learning from both this case and other child safeguarding practice reviews has resulted in a change of safeguarding practices and activities," said Stephen Eccleston, the partnership's independent chair.
West Mercia Police's Assistant Chief Constable Rachel Jones said an initial review into the force's involvement with the family had resulted in "enhanced training" for officers and staff "to ensure they fully understand the signs of vulnerability, that they are professionally curious and don't take information on face value."
The force referred itself to the Independent Office for Police Conduct (IOPC) over its involvement.
An IOPC spokesperson said the review was ongoing but had not identified any conduct issues for any officers involved at this stage.
"We are looking at the force's response to concerns about Alfie's welfare and we have so far examined a large number of documents including police logs, witness statements and relevant policies, along with body worn video."
