An investigation into the death of a Saguenay-Lac-St-Jean child has found serious shortcomings in efforts to protect them after a report was filed with the Directorate of Youth Protection.

The investigation focused on the directorate’s actions during the reporting, immediate risk assessment, file prioritization, wait times and absence of intervention between the initial report and the child’s death.

According to the report, issued by the Human and Youth Rights Commission, there were problems at all stages.

 The victim died in July 2016, less than a month after a report was filed.

According to the commission’s investigation, the child had been seen by several healthcare professionals, but none reported their guardians to DYP, despite her situation being evidently “worrisome.”

After a report finally was filed, the file concerned “educational negligence,” despite the child showing obvious signs of several injuries.

The investigation also showed serious problems with how files were prioritized as at the time of death, first contact with between DYP officials and the guardians had not yet been made after 23 days.

The DYP has until Oct. 1, 2017 to inform the commission of what steps it’s taking to implement the investigation’s recommendations, including new training for staff and revisions to existing practices.