The Laming report is a damning verdict of every official body involved in the case of Victoria Climbie.

Lord Laming's report, published on Tuesday, details a catalogue of administrative, managerial and professional failures and concludes that the eight-year-old's life could have been saved on 12 separate occasions.

Before her death she came into contact with four social services departments, three housing departments, two specialist child protection teams of the Metropolitan Police, two hospitals and a families centre managed by the NSPCC.

Ominously, the inquiry warns that many of the concerns identified in Victoria's case are replicated elsewhere in the country.

One of three broad suggestions in the 400-page report is for a new national organisation responsible for children and families and for a new children's commissioner to head-up the new commission.

Lord Laming also demands a fundamental change in the mind-set of managers in key public services so they see their role in terms of the quality of services delivered at the front door rather than in administrating bureaucratic and sometimes self-serving procedures.

He also urges a clear and unambiguous line of managerial accountability across public services.

The report does not see the need for new laws or the tightening of current regulations as the legislative framework is "fundamentally sound".

"The gap is in its implementation," he concludes.

Blame is mainly placed with the organisations that should have prevented Victoria's death, though the people who had direct contact are not absolved of responsibility.

"It is not to the often hapless front-line staff that I direct most criticism for the failure to protect Victoria. True their performance often fell well short of an acceptable standard of work," he concludes.

"The greatest failure rests with the senior managers and members of the organisations concerned whose responsibility it was to ensure that the services they provided to children such as Victoria were properly financed, staffed and able to deliver good quality services to children and families. They must be accountable."

The report contains 108 recommendations, many of which are described as "disarmingly self-evident". Of those, 46 should be implemented in three months and a further 38 in six months.

"That they have had to be made should be a reproach to everyone with responsibility for the safety of children. Now is the time for every chief executive to conduct a thorough audit of the quality and effectiveness of services to children and families and to have in place - before summer - an action plan to speedily remedy any defects. Nothing less will do," Laming warns.