Carol Chafe, the Newfoundland and Labrador child and youth advocate, says the services provided to a 16-year-old boy who started a fatal fire in a boarding house in downtown in St. John's in 2011 were inadequate.
"There were times when his voice was not heard, his rights were not respected, and his rights to services were not upheld," said Chafe.
In a news conference on Tuesday morning, Chafe laid out a long list of failings by Child Youth and Family Services, Eastern Health and the Royal Newfoundland Constabulary. She also outlined 30 recommendations as a result of the investigation.
Carlos Escobar Medina, 54, was found dead in the 101 Springdale Street house that was destroyed by fire on Nov. 27, 2011.
Medina was a resident of the boarding house. The boy had been also been living there without direct adult supervision.
The teen pleaded guilty to manslaughter in May 2012, and was sentenced to two years in custody and one year under community supervision.
Report needs quick response: Parsons
Andrew Parsons, the Liberal critic for Child, Youth and Family Services, said Chafe's report needs a quick response.
"This goes right to the top when you've got some of your main departments in government that are not working together and we have children that are being affected and we have people that are dying. It's gross negligence."
Child, Youth and Family Services Minister Paul Davis said the system has been improving since the incident on Springdale Street.
"We were going through a process of transition as a department at that time," said Davis. "And the recommendations that are made in her report appear to be similar to other recommendations we've seen in other reports, recommendations that we've implemented."
Chafe said she will follow up with government to make sure it acts on her recommendations.