Jeffery Baldwin died in 2002 in the care of his maternal grandparents. The case received intense media attention at various times over an almost eight-year period. Along with other public documents, the media coverage permits an analysis of the practice errors by Child Protection Services that are related to the failure to protect Jeffrey. Nine key themes emerged around core child protection practices: opening a file; the role of prior knowledge; issues related to assessment; knowing the child and their needs; the role of culture; case supervision; the child as the client; the enmeshment of child abuse; and the role of stability and healing. This analysis offers key lessons to be learned from such cases.