The serious case review by Birmingham Safeguarding Children Board into the case of Paul Wilson, jailed in 2011 for raping a child at Little Stars in Birmingham, concludes that poor nursery management and the failure of the local authority and Ofsted to investigate concerns raised about his behaviour meant that the abuse was missed.
It raises the spectre of Plymouth nursery worker Vanessa George, jailed in 2009 after admitting abusing children at Little Ted's, not just because of the horror of the perpetrator's abuse but also because of similarities found in the nature of the failings in practice and management.
Crucially, the crimes of both abusers were only revealed after they were picked up by the police, who were investigating other unrelated incidents.
The Birmingham report said there were missed opportunities to intervene earlier and that, 'It was entirely fortuitous that the offending came to light via a route other than robust responses to concerns within the nursery.'
In the most recent case, an accusation of online grooming against Mr Wilson by a 13-year-old girl led to his arrest. Ms George was first arrested after police received a tip-off in connection with indecent images of children being distributed by email. Mobile phones, social media, grooming on the internet and blurred boundaries feature in both cases.
The Birmingham report said there was evidence of close relationships between some parents and staff, with staff being friends with parents on Facebook.
Sue Chambers, early years consultant and senior LEYF associate, said all early years settings should have a social media policy, and have no qualms about banning nursery staff from being friends with parents on Facebook, even if they are already linked online.
'I would say unlink and I would say that anyone who blurs the line between professional and social would face a disciplinary.'
It also saves awkwardness for staff because 'they can say they are not allowed to be friends on Facebook because it is a safeguarding issue', giving them security as well as boundaries.
With Twitter, she recommends that staff state in their profile that 'all views are their own', should not mention the name of the setting where they work, and could consider a pseudonym. Staff can also block parents from following them on Twitter.
Laura Henry, managing director of the Childcare Consultancy, agrees it is important to have a robust professional code of conduct for social media use, but says, 'It is very difficult for a manager to police the use of social media, in terms of who their staff connect with and how they share information.
'Consequently it may be worthwhile to explore with staff what is meant by the term "keeping a professional stance" and how they adhere to safe practice while at work and outside of work.'
Des Forrest, nursery manager at the House of Rompa, said the issue of Facebook was, 'a hard one, as some of my parents were actual friends before they had children and before they attended the nursery. However, the nursery policy does stipulate no nursery business or any information or photographs to be downloaded or discussed - no ifs or buts; instant dismissal.'
The recent case also highlights the need for nurseries to have strict policies about taking students on or employing friends and family. The review highlights 'lax recruitment processes', including Paul Wilson working without a CRB check.
His mother had been the manager at the nursery, making it easier to get a placement there, and subsequently he worked to provide cover during the summer before being offered a contract.
Ms Chambers said nurseries should have very clear vetting policies, and that there should be evidence of CRB checks and qualifications before taking staff on. She believes it is inappropriate to take students on if they are known to the nursery.
In the wake of the Vanessa George case, much was made about the need for policies about mobile phone use.
In the Birmingham nursery, staff were not allowed to use their mobile phones, but they were kept in the pockets of coats, which were hung in the kitchen area. Wilson worked in a room next to the kitchen, which made it easy for him to retrieve his phone, the report said.
Ms Chambers said that nurseries need to ensure that mobile phones are locked up in the office and that if staff need to make calls at lunchtime they should only use them off the premises and return them to the manager to be locked up afterwards. Such a policy would protect children, and protect staff from any allegations, she said.
Ms Chambers also said that all nurseries need to have an intimate care policy, saying, 'You need to have a policy that says that doors must be left open at all times and that the nappy changing area must be visible.'
Experts says that staff must be able to feel that they can raise their concerns safely.
Ms Chambers said, 'The policy needs to be incredibly clear and very powerful, with guarantees that it (the concern) will be investigated.'
Laura Henry added, 'We need to clarify within the sector what we mean by whistleblowing, especially in the wider context of safeguarding and child protection.
'As a starting point, reflect on how an emotionally safe environment for everyone is linked to your values and ethos.
'Are your staff team able to speak openly and with confidence about issues that may be of concern to them with management and each other? Equally, what are the procedures in place that show the steps a member of staff may take if they had concerns?'
For babysitting, experts agree there must be clear guidelines, but hold different views.
Ms Chambers said babysitting should not be allowed, even if it is a private arrangement.
Laura Henry said, 'I know some nurseries offer this as a service. Some owners accept no responsibility for babysitting and state it is a private arrangement between the parent and staff member. Staff and parents need to be reminded they are not covered under the nursery's insurance and for staff to be mindful about confidentiality. There are also other issues regarding the relationship between the child and staff - such as favouritism developing.'
But she adds, 'Personally, as a parent who had no extended family living locally to me to call on for babysitting, I would have rather used someone who my child knew from nursery rather than a stranger. If we are talking about consistency of care and attachments, from the child's perspective, this arrangement makes sense.'
What is clear for all is that robust policies and procedures must be in place and that all staff must read the safeguarding policies and understand what their responsibilities are.
The experts I spoke to also emphasised the need to ensure that there is not a backlash against employing men. 'There is a real concern that we don't demonise men,' said Ms Chambers. 'This is not a male issue. This was poor practice, poor management and poor communication.'