An independent review of the Sara Sharif case has identified multiple failings from agencies before her murder in Surrey in 2023, following two years of abuse.

The child safeguarding practice review, published on Thursday, said there were “clearly several points in Sara’s life, in particular during the last few months, where different actions could and should have been taken” by the authorities.

“The system failed to keep her safe,” it added.

Responding to the report, the Children’s Commissioner said the case was a “catalogue of missed opportunities, poor communication and ill-informed assumptions.” The education secretary said there had been “the glaring failures” across all agencies.

From before she was even born Surrey Children’s Services, Surrey Police and the Family Court knew of the domestic violence in her home.

The review authors said her father and stepmother were “a lethal combination”, and that “with hindsight it is clear that they should never have been trusted” with her care.

Here are five of the key failings identified by the review.

Warning: This story contains distressing details

When Sara Sharif’s case was first in the family court in the early months of her life, social workers from Surrey County Council wanted her to be removed from her parents for her safety.

But after the initial court hearings the plan changed.

The review found that the “social workers felt very frustrated” by this, saying voices were not heard.

They felt that in court “the views of the children’s guardian took precedence”. The children’s guardian is an expert appointed by the court to “represent the best interests of a child”.

The review authors said that where the children’s guardian and local authority social workers have differing views, the difference of opinion should be summarised clearly for the judge.

When Sara Sharif’s father remarried and applied for custody, an inexperienced social worker was asked to produce what is called a Section 7 report.

But the review found the report was missing “vital information and analysis” because the files that Surrey Children’s Services held were not “thoroughly reviewed”.

By chance the judge who heard the case, Alison Raeside, had sat on the earlier hearings, but she was not reminded of some key facts.

For example, Sara’s father Urfan Sharif had a history of “domestic abuse and past violence to the children”. He had been told to complete a domestic abuse perpetrators programme before having unsupervised contact, but he had not.

When in March 2023, Sara’s school reported to Children’s Services that she had a golf ball-sized bruise on her cheek the request for support was graded “Amber”.

This meant it should be dealt with within 24 hours. The social worker did not check what information Surrey Police held on the family, and they did not speak to the school to inquire more about Sara’s change in demeanour.

She had gone from a bubbly child who loved singing to someone who was “quiet and coy”.

Urfan Sharif told the social worker that Sara had “lots of marks because of the machinery she was hooked up to when born prematurely”, which was a lie. The outcome was “no social work action”.

Five months later Sara was murdered by her father.

The next month Urfan Sharif took his daughter out of school. The review found that she “effectively disappeared from view”.

Surrey County Council had a policy of making home visits to children being home-schooled. The Sharif family had recently moved from a small flat in West Byfleet to a house in Woking. The school knew this and had informed the Council who owned both the homes anyway.

The review found that “address on the referral form sent by the school was the new address but the old address remained on the electronic system used by the inclusion team.”

It meant that when the home education team went round to check on Sara on 7 August 2023 they went to the old address.

The next day Sara – already tortured, battered and burned – was murdered by Urfan Sharif and her stepmother Beinash Batool.

Neighbours of the Sharif family did at times hear things that worried them, but the review found that “they were worried about reporting concerns about what they heard within the family’s home. They feared being branded as being racist, especially on social media”.

Sara started wearing the hijab in 2021 when she was only eight years old, even though her stepmother did not.

The review found that the “school showed appropriate curiosity by talking to Sara and stepmother and accepted the explanation that this was linked to Sara’s interest with Pakistani culture following a visit to her paternal grandparents in Pakistan”.

In the last months of Sara’s life the the hijab hid the bruising and injuries to her face and head.