Shirley Turner drowned herself and her 13-month-old son Zachary in August 2003. (CBC)

A hard-hitting report into Newfoundland and Labrador's child welfare system has found significant gaps in coverage, including failed investigations into child sexual abuse.

The report, called a clinical services review, identified scores of issues, many of which have been flagged in the past, such as high turnover of staff among child protection workers and inadequate resources to manage the system.

The report, delivered in December but not released publicly until Tuesday, found inadequate intervention to prevent sexual abuse or to assess the risk of abuse, incomplete investigations into allegations of maltreatment of children in foster care and even some serious complaints that were not investigated at all.

The report looked at 400 child protection cases from 2007, and found 68 of them had deficiencies that could affect a child's well-being.

The report was commissioned partly to assess how the child, youth and family services system has changed in the wake of the 2003 drowning death of Zachary Turner, a 13-month-old boy who was killed by his mother, Shirley Turner.

Turner drowned herself and her child in Newfoundland's Conception Bay after fighting extradition to the U.S., where she was wanted for a murder trial in the shooting death of Zachary's father, Andrew Bagby.

The report, by three external consultants led by Toronto child protection expert Susan Abell, found many of the problems identified in a formal report into Zachary Turner's death are still problems. The authors blame failures on a workforce that is not only unstable, but underfunded and undertrained.

It also identified an unfocused leadership with conflicting visions and priorities, and said a wide-ranging plan is "urgently required" to overhaul a system, a process the authors say will take several years.

Joan Burke said government officials will review past child-protection cases to ensure errors were not overlooked. (CBC)

"If this report is received as another that can be responded to with a patchwork of 'quick fixes,' it will fail to make a significant improvement and be viewed as a disincentive to those working in the system," the report says.

"The lives of children in Newfoundland and Labrador depend on this."

The report helped guide the government in the creation of the Department of Child, Youth and Family Services, which brought services from other agencies under one roof.

Joan Burke, appointed minister of the new department last month, said government accepts the report's conclusions.

She said government will "ensure that any services or any gaps in any services are identified and the appropriate intervention takes place."

As well, staff have been directed to check on older cases.

"[With] the cases that were referred and screened out, and despite being screened out, they did have a file saying they had a history with child services, I want all those files that were screened out that had a previous history to be reviewed again."

David Bagby, Zachary Turner's grandfather, said he does not know if the review's recommendations will fix anything, although he said at least the problems have been identified.

"There's nothing very specific in here that I can say, "There, this would have saved Zachary,'" Bagby told CBC News.

'It seems like if all of this had been in place, there would have been a much better chance. That's got to be a good thing."

Liberal Leader Yvonne Jones said she found the report startling.

"The authors of the report are surprised that there [are not] more cases [like] the Zachary Turner case, and that is a pretty strong statement to make when you're dealing with services being provided to children in this province," Jones said.