VICTORIA - British Columbia's independent children's watchdog says the province's child protection system failed four children on numerous levels before their deaths.

A report released Wednesday by Children's Representative Mary Ellen Turpel-Lafond examined the roles of the many agencies who crossed paths with the children and their dysfunctional families, including police, government, doctors, coroners, child-care workers, teachers and the aboriginal community.

"I ask you to move past the easy focus of assigning blame and the gruesome details of the deaths,'' said Turpel-Lafond during a press conference.

Turpel-Lafond said the report applies to issues of care she identified in northern B.C., but evidence suggests the care system in the rest of the province isn't any better.

"The representative's investigation has determined that the system failed these northern B.C. children on numerous levels,'' said the 150-page report, entitled From Loss to Learning.

"This knowledge must drive us to seek out the enduring lessons for today's practitioners. The silencing of these children's voices must stir us to move from loss to learning.''

Turpel-Lafond said she met with family members of the dead children before releasing the report, which is now in the hands of the government's select standing committee on children and youth.

The report said poor safety standards, lack of thorough medical assessments and insufficient communication between the Ministry for Children and Family Development and professionals in the community played roles in the deaths.

Turpel-Lafond said the level of care each of the four children received from government and service agencies was below what should be reasonably expected, but the memories of the children will be better served if the focus is placed on what could have been done to prevent their deaths.

She also said the review's 11 recommendations can be used to support child-care workers and the Ministry for Children and Family Development because their jobs is to protect vulnerable children.

"The investigation into the deaths of Amanda, Savannah, Rowen and Serena has identified important lessons for the child-serving system,'' the report concluded. "The legacy of these children must be that we learn from those lessons, and move forward. The legacy of these children's lives must be a better system.''

The children ranged in age from seven months to four years old and each had a family history of involvement with the child welfare system.

Three-year-old Savannah Hall was found unresponsive in her foster home in Prince George, B.C., on Jan. 24, 2001. She died in B.C. Children's Hospital two days later.

A coroner's inquest in November 2007 was told that Hall slept in a crib equipped with leather harnesses.

The inquest found Hall's death was a homicide as a result of suffocation. Criminal charges were not laid but the inquest made 26 recommendations.

Rowen Von Niederhausern, of Terrace, B.C., was 14 months old when he died in August 2002. A coroner's jury found he died of brain injuries as a result of accidental shaking.

Serena Leona Marie Wiebe died in Fort St. James in June 2005. She was just seven months old.

And last June, another coroner's jury concluded the 1999 death of four-year-old Amanda Simpson was a homicide caused by non-accidental head trauma.

The jury called on the B.C. Ministry of Children and Family Development to take steps to improve its ability to protect children, upgrade training for social workers and spend more on resources targeted at child protection.

Simpson died on Nov. 2, 1999, three days after suffering extensive head and body injuries while at home in the care of her stepfather.

Turpel-Lafond said more focus needs to be placed on making improvements to the working lives of front-line workers in the north.

"This is not an intractable problem,'' she said. "It can be addressed.''

She called for the formation of an aboriginal council for the north to provide a focal point for the safety ands well-being of aboriginal children.

Seventy per cent of children in government care in the north are aboriginal, she said.

Three of the children who were the focus of her report were aboriginal.