It was a Third World death in a First World city. A 3-month-old Hong Kong girl starved to death because her parents claimed they didn't have enough money to feed her. When she died in hospital last summer, the little girl without a name weighed 0.21 kilograms less than she had at the time of her birth. At 2.68 kilograms, her frail body was half the normal weight of a baby her age.
In May, her parents were each sentenced to six years in prison for manslaughter. Cheung Po-sham, 31, and her boyfriend Wong Chi-chung, 22, said they had added too much water to their daughter's baby formula because they could not afford to keep buying it.
Sentencing the parents, Judge Peter Line posed a poignant question: "How could a child starve to death in a densely populated modern city where health care and social welfare is freely available to those in need?"
So what went wrong? The facts, as outlined in the court case, appeared sketchy. Line said that although it was tempting to criticize the system, such criticism should be resisted because the court lacked information.
One fact that did emerge was that the family was known to the Social Welfare Department because of a previous incident in which Wong had been placed on a good behaviour bond for slapping one of Cheung's two sons.
The department said its child-protection unit had been following the family since October 2007 but ended that intervention in February 2009 because the family no longer had a problem with abuse or the need for further welfare service.
At that time, Cheung would have been in the last weeks of her pregnancy with her daughter. Yet, as the judge pointed out: "This family was obviously one that displayed many of the indicators that would spell out risk for their new-born child. This was a family known to the social welfare services, yet there was no home visit after the arrival of the new baby."
After the birth, the baby also appeared to have escaped the radar of the Health Department's Comprehensive Child Development Scheme and its Maternal and Child Health Centres, which aim to provide health care for all new-borns and support for their parents.
All mothers who give birth at government hospitals are advised to attend one of the health centres within one week. But Cheung had not even registered the birth or visited a health centre, so her baby's dwindling weight and poor health went undetected by those who could have helped.
The reasons why are not known, and what steps, if any, were made by the Health Department to chase her up have not been made public.
According to Priscilla Lui, director of the Against Child Abuse group, the case highlighted failings in the child-protection system, and at the root of these was the government's reluctance to address these issues.
"Over the past 30 years, things have not improved," she charged. "Children are being neglected, left unattended and have died. Why are these things still happening?"
"In some 30 countries, they have appointed child commissions and commissioners, but Hong Kong is hesitant, which is a great pity," Lui said. "In my eyes, this is a form of neglect and discrimination of children."
Both Lui and Dr Patricia Ip of the Hong Kong Committee on Children's Rights said there are lessons to be learned from the tragedy, one of which is the need for a prompt and efficient review for unnatural child deaths or serious injuries.
They said the Social Welfare Department's current child death review system was limited, took too long and lacked legislation to back it up.
"Hong Kong is supposed to have a safety net for children and families," Ip said. "Such a multisystem failure warrants an inquiry. Otherwise, this child will have died in vain."
Ip would also like to see a system similar to other countries' in which new mothers are visited by health officials at home within days of their discharges from hospital.
Would such safeguards have made a difference? Might a health visitor have spotted the baby's dwindling weight and intervened? Those questions remained unanswered - and even if answers are one day forthcoming, they would come far too late to save a baby girl with no name.