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The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found.
Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday.
The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing".
The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest".
Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home.
Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided".
He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later.
"Instead, a cover-up began on the day that she died, propped up by denial and deception."
Frimley Park Hospital in Surrey, where Lizzie was born, initially failed to diagnose a tumour which probably led to brain damage, the report said.
Her condition may have worsened due to mistakes at Great Ormond Street Hospital, which also arranged inadequate home care, it added.
Dr Kirkup said there was "clear evidence that some individuals have been persistently dishonest... and that this extended to formal statements to police and regulatory bodies."
He said a "failed" police investigation and a refusal by some health workers to give evidence to the inquiry should be investigated by professional bodies.
Publishing the report, health minister Nadine Dorries said it described a "harrowing and shocking series of mistakes associated with the care received by Elizabeth and a response to her death that was completely inadequate and at times inhumane".
The baby's parents, Anne and Graeme Dixon, from Church Crookham, said further evidence of wrong-doing was not used by the inquiry.
They said: "While we are pleased to see... that some of the blatant lies, deception and cover-ups of mistakes and incompetence have been called out, we are disappointed that certain aspects of Lizzie's care and the cover-up have not been addressed."
Dr Timothy Ho, medical director at Frimley Health NHS Foundation Trust, said: "We welcome the publication of this report and would like once again to offer our sincere and heartfelt apologies to Elizabeth's family.
"Our care for neonatal infants, our support for bereaved parents and how we investigate concerns have changed beyond recognition over the past 19 years, but we will carefully consider the report and its recommendations with a commitment to taking any action that is needed."
A spokesperson for Great Ormond Street Hospital said it was working to "identify the actions we need to take to learn from this case".
"It is clear that Elizabeth and her family have been let down at so many points during her life and following her death and we are very sorry for our role in this," the spokesperson added.