Baby Ebony was repeatedly failed by the agencies tasked with her protection before her horrific death at the hands of her father, South Australia's deputy coroner says.
The four-month-old suffered multiple skull fractures, more than 50 broken ribs and fractures to her collarbone, fingers and toes before her death in Adelaide in 2011.
Deputy state coroner Anthony Schapel has called for a national child protection database to be established to prevent further deaths at the hands of violent and neglectful parents amid scathing comments aimed at Families SA, SA Police and other agencies.
Ebony was identified as high-risk at birth after a hospital social worker raised concerns about her young mother, who had been under guardianship in her home state of NSW.
Mr Schapel's inquest heard that Ebony's father, who has been jailed over her death after pleading guilty to criminal neglect, had fathered another child in his home state of NSW.
The NSW Department of Community Services had an extensive file on the father suggesting "a propensity towards ill-treatment of children", Mr Schapel said.
But Families SA did not investigate the father's background.
"The failure of the South Australian authorities to inform itself about (his) history was a serious oversight and I have little doubt that proper inquiry in respect of this topic could have been enough to have prevented Ebony's death," Mr Schapel said in his finding on Thursday.
"It could and should have altered what ultimately became a casual approach to her protection on the part of Families SA."
Ebony presented at hospital in August 2011 with a broken femur which a radiologist believed was suspicious, but authorities accepted the father's explanation that he had accidentally dropped her.
Mr Schapel also criticised SA police over their handling of a triple-zero call to the family home a month later from a neighbour reporting a "domestic", describing it as another missed opportunity to protect the infant.
Families SA ultimately closed Ebony's file, and other agencies failed to persist with visiting the girl after her parents resisted contact with them.
Opposition child protection spokeswoman Rachel Sanderson said all closed child protection files should now be reopened to ensure they were properly handled.
Ebony's mother, who was placed on a two-year good-behaviour bond after pleading guilty to the criminal neglect of Ebony in 2014, said she was pleased with the coroner's recommendations.
She said she had lived in fear of her former partner but had no knowledge of his history of child abuse before their daughter's death.
"If Families SA actually connected with me and told me about (his) background, I would have left straight away," she told reporters outside court.
"I didn't witness any abuse or anything like that. I believe my daughter would still be alive today if they did act.
"She was my little princess. She was always smiling. I miss her every day."
Child Protection Reform Minister John Rau said in a statement that the government would carefully consider the coroner's recommendations and respond as soon as possible.
