A new watchdog report that examines child fatalities details problems in the state’s child protection agency.

The Office of the Child Advocate, which was established in 2017 to help reform the state’s Division of Children, Youth and Families, issued the report based on six critical incident DCYF cases. It calls for “a shift from blame and shame to system accountability,” according to a news release on the OCA website.

“We used the same science now common in safety-critical industries like aviation and nuclear power, to examine the influences on case decision-making so we can understand when and how we can prevent tragedies,” Child Advocate Moira O’Neill stated in the news release, which added that safety science is an integrated process of evaluation that cultivates a safe environment for honest, open problem solving.

The report identified 10 themes in the system that affected casework decision-making and agency action. These included “relationships and communication with other agencies, resource constraints, insufficient technology, and knowledge gaps.”

According to a story posted on seacoastonline, O’Neill wrote in the report, “Yes, police should call the Division for Children, Youth and Families when children are in harm’s way. However, DCYF should call police, too, and neighbors should call them both.”

“As a community, we all carry responsibility for the safety and wellbeing of children,” O’Neill added. “That includes ensuring well-resourced and effective prevention programs are available to families, and for when families struggle, child protective services that are equipped to intervene and ensure children are safe.”

In response to the report, the DCYF stated in a news release, “DCYF is an important stakeholder in the broader child welfare system. As the OCA acknowledges in her the opening paragraphs of her report, child safety is a collective responsibility. While the OCA drew broad conclusions after speaking to about a dozen DCYF staff, representing a small sample of the broader workforce, we encourage the OCA to consider broadening its work to include more voices from within DCYF and from outside the agency.”