The death of a three-year-old Indigenous boy at the hands of his foster parent was the "direct result of the fundamental failure" of children's services workers involved with the case, a fatality inquiry judge has ruled.

In a report into the death of Kawliga Potts, Judge Ferne LeReverend offered a scathing indictment of the workers who failed to follow up on clear signs the child was being abused at the hands of his foster mother, Lily Choy.

"Evidence of abuse was present," the judge wrote in a 20-page ruling released Friday. "It was known to five different case workers involved in Lily Choy's home. None of the workers addressed their minds to what needed to be done to save Kawliga.

"Kawliga Potts' death was a direct result of the fundamental failure of everyone connected with this child to do their jobs," LeReverend wrote.

The judge noted that no one involved in the case followed the rules and procedures that were in place. A special case review report completed after the boy's death commended the workers for "exceeding policy expectations for face-to-face contact with him."

Kawliga died of a brain injury in an Edmonton hospital on Jan. 26, 2007, less than two months after the province put him into Choy's care.

Choy was convicted of manslaughter in his death in 2011. After two appeals, her initial sentence of three years was increased to six years and then to eight years.

Children's Services Minister Danielle Larivee was not available for an interview Friday.

Her spokesperson, Aaron Manton, would not say whether the case workers still worked for the government of Alberta or whether they had faced any disciplinary action.

Manton said the government has improved screening for foster parents, and made it mandatory to provide supports for their first three months and to assess them after six months. Manton said foster parents undergo mandatory reassessment if more children are added to the home.

In the fatality inquiry report, the judge laid out numerous ways the workers and system failed the boy. They include:

Choy's application to become a foster parent was not properly vetted. Choy failed to disclose her past in Switzerland where she had two children with different fathers. Both men had gone to court to get access to their children. Choy left for Canada without notifying them. One of the men tracked her down, and there was a court application underway in Alberta when her foster application was filled out.

According to a foster care committee report in 2006, Choy was only supposed to care for children over the age of five without complex needs. When she called to be upgraded to a "Level 2," the request was granted without additional assessment, even though there were questions about her capability

Kawliga was assessed as a Level 2 child, but was not placed with a foster parent who could help him with his needs.

The child's grandfather asked that the boy be placed with him. That request was never followed up by the caseworker.

Three siblings ages 10 to 14 were placed in Choy's foster home. The judge said that should not have happened, as she did not have the licence for that number of children.

A respite foster parent who cared for Kawliga over Christmas 2006 called the boy quiet, shy and obedient. A week later, Choy claimed the boy had become "lunging, self-abusive and unco-ordinated." Said the judge: "No one considered whether Lily Choy contributed to or made up these allegations."

Choy blamed the Kawliga's biological father for bruising on the boy. On Jan. 8, 2007, a doctor who examined Kawliga said multiple scars and bruising raised concerns about child abuse, in a letter found at the office the day the boy died. The caseworker denied ever seeing it.

Choy reported more bruising and abuse on Jan. 16, 2007. She again blamed a visit by the biological father, even though he hadn't seen Kawliga since late December. When asked about it during the inquiry, the caseworker said she didn't think she was in a position to make a determination on whether the bruises were a sign of abuse. She didn't think she needed to refer the matter to the child advocate or to a doctor.

The siblings in the home said Choy was abusing them psychologically. One of the teenagers in the home reported it to her case worker. Instead of reporting it herself, the worker told the teen to write to the child advocate

The judge said the case worker directly involved with Kawliga knew of the abuse, neglect and abandonment he had faced, but failed to tell the placement unit responsible for finding him an appropriate foster home.

The judge said the five recommendations in the report were taken from a column, published in the Edmonton Journal in January 2017, by Tim Richter, chair of the 2014 Alberta Child Intervention Implementation Oversight Committee.

Richter's recommendations include disclosing the names of children who die in care and to expand the child advocate's role to help families whose children have been apprehended by the government.

"Reading between the lines of this report, I sense there is frustration from the judge," Richter said in an interview on Friday. "She said recommendations were made and implemented but the deaths of kids in care continued. And another review panel has been appointed to do another complete review.

The legislature passed amendments last spring giving the child advocate responsibility to investigate the death of every child who dies in care.