THE obvious answer as to where any blame should lie in the horrible case of Kimberley Baker was answered quite comprehensively at the crown court earlier in the spring, when her parents, pictured, were given five years each for manslaughter.

You can't get away from that, but that hasn't convinced many people that nobody else is at fault for the situation. Frankly, if all was rosy in the world of social services and health visitors you wouldn't need 20 recommendations to stop things like this happening, as was announced this week.

With some of the plans they want to bring in, it's astounding that it's not routine practice already: "Children's case files should have a properly-maintained chronology of significant events" was one on the list. Really? So what condition are these files - which, don't forget, deal with kids who are at risk - in at the moment?

Now, we've been told that none of the staff dealing with this did anything wrong and all followed procedure. This may well not be wrong - I'm not interested in who exactly visited at what time and why, because this isn't a witchhunt, but if everyone concerned acted entirely appropriately and according to the law then the system of child protection in this town and across the country is deeply flawed.

I'm particularly worried that a health visitor was worried that the family home was dark, smelly unfurnished, but decided that this was an environment issue, and not a welfare issue. This is a bit foxing, because most people who found young children living in a house with dirty nappies scattered around would probably want a bit more action taken than merely referring it upwards for possible action.

Because this isn't just an unusually messy house - it was lived by a family by who had been on and off social services' radar for years, and should have had an eye kept on them, even if this does not have to translate to 24-hour monitoring.

But the craziest point in this - and again this is a matter of the law at the moment rather than the individual - is that the social workers don't have the right to see a child in this situation. You'd like to think that the common sense sequence of events would be that the dirty conditions would ring alarm bells, and the social worker - who should know that there was a 11-month-old baby in the house - would make sure that she saw Kimberley. If he or she was refused access, then that would surely be a legitimate cause for concern and higher authorities could kick into action almost straight away.

Yes hindsight is a wonderful thing, but it shouldn't be forgotten that one of the reasons we have social services departments and their like is that there are cases where children are being brought up by parents who quite manifestly can't cope.

Hearing that health visitors knocked on the door seven times between December 2004 and March 2005 and never saw the child is another worry. If there was cause to go round, surely every time the door wasn't answered (even though there were occasions when they knew people were in the house) should ratcheted up the concern, not just left it as it was.

As already said, the immediate fault for Kimberley Baker's death lies at the pair who did not feed her. But it's sad, and worrying, when the safety net that should catch children in this most horrible of positions didn't work.

And if one good thing can come out of this whole sorry affair, it should be that rather than just tweaking some practices and adding some new ones, the system was looked at from top to bottom to make sure that the large gaps in the net, such as the one that Kimberley Baker fell through, are sewn up.