Warning signs that might have prevented a predatory paedophile raping children at the nursery where he worked were ignored, a serious case review has found.
Paul Wilson, 23, was jailed for life in 2011 after pleading guilty to two counts of rape and more than 40 offences relating to grooming children online.
He had been able to take "advantage of weaknesses in the system," Jane Held, independent chair of the Birmingham Safeguarding Children Board (BSCB) said in a statement.
"The review found that it was known by the nursery, Ofsted and the local authority that Wilson had a 'special relationship' with [a] child which should have raised the alarm and been examined in more detail," said Ms Held.
"The lack of supervision of the perpetrator, failure to understand the risks of 'special relationships' with individual children, the layout of the nursery and the weak safeguarding practice within the setting combined to create an environment where the external factors that might have deterred the perpetrator from abusing the child were missing.
"The local authority did not communicate to the relevant agencies and investigate when the initial child protection concerns were raised. In addition there was a failure by Ofsted and the local authority to properly investigate concerns and a lack of rigour and depth to the nursery inspection process."
Wilson, from Birmingham, worked at the Little Stars nursery.
Outside of work, he befriended young girls online, often posing as a child, and encouraged them to expose themselves on a webcam.
Subsequently, he would use the images to blackmail the children into carrying out sex acts.
At the time of his sentencing, he was described as "a very, very dangerous individual," by Detective Inspector Kay Wallace of West Midlands Police who led the investigation into his activities.
The Serious Case Review has made eight key recommendations.
Ms Held said: "Parents should be able to trust the people they leave their children with to ensure that children are properly protected. In this case there were unfortunately a number of weaknesses in the way that nursery was run and a number of opportunities to intervene earlier and prevent the continuation of abuse which were missed."
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