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The homicide of Tina Fontaine‘s father in 2011 “profoundly impacted” her life and started her on the road to her own murder, according to a report released by the Manitoba Children’s Advocate Tuesday.

2:09 Tina Fontaine failed by every system designed to help her, says report into her death Tina Fontaine failed by every system designed to help her, says report into her death

The report, entitled A Place Where It Feels Like Home: The Tina Fontaine Story, said every system Fontaine came in contact with failed her after her father Eugene’s death, and in the months leading up to her murder.

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“At times, particularly in the final months of her life, some of those services were unavailable, not easily accessible, or ill-coordinated, failing to provide the supports and interventions she desperately needed.” Tweet This

Two main themes were found in the services Tina received, said the report.

“First, following the death by homicide of her father, the education, mental health, victim support and child and family services from which she was entitled to receive services missed opportunities to identify concerns and intervene early to prevent the escalation of harm.

“As Tina journeyed through her grief to find a sense of belonging, she became disconnected from healthy networks of support. Tweet This

“Second, crisis intervention and emergency response services including the child welfare system did not safeguard her from sexual exploitation.”

A star blanket featuring the images of Missing and Murdered Indigenous Women. Brittany Greenslade/Global News

Tina, who was 15, left her home on the Sagkeeng First Nation to reconnect with her birth mother in Winnipeg in June 2014.

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Her father was beaten to death in 2011 and two men were convicted of manslaughter in his homicide.

Tina had interactions with child-welfare workers, police and the health system before her body was found in the Red River wrapped in a duvet cover and weighed down by rocks that August.

Her death renewed calls for a national inquiry into missing and murdered Indigenous women and inspired volunteer groups such as the Bear Clan Patrol, an Indigenous led neighbourhood watch group.

In the years after her father’s death, “victim services neither met directly with Tina nor did they arrange a single counselling session for her to help her manage her loss and grief,” said the report.

Her interactions with CFS showed they had several concerns for her well-being, noting she was suffering from mood swings, was self-harming, acting out physically towards her family members, using pot, not attending school and ran away at least three times.

Tina’s grandmother also told CFS workers she had called RCMP about an adult man Tina was chatting with online, one of several she was talking about meeting with in Winnipeg. RCMP do not have a record of this contact.

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Despite CFS’ concerns, Tina did not receive the help she needed, according to the report.

The report makes five major recommendations, revolving around education, mental health, victim services, Child and Family Services and sexual exploitation.

The five major recommendations made in the report. Brittany Greenslade/Global News. Brittany Greenslade/Global News

Advocate Daphne Penrose said despite the recommendations, to blame only the services surrounding Tina is short-sighted and serves only to “reinforce” existing structures and beliefs.

Tina didn’t spend much time in the system before she died and had a “significant protective force” in her great-aunt, Thelma, she added.

“The event that changed Tina’s life was the violent and sudden death of her father.” Tweet This

Tina’s family members say before the report was released that while they will never get Tina back, they hope the report will make sure no other children fall through the cracks.

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Penrose says the same situation would happen today with a child in Tina’s situation – saying they would fall through the cracks again — Brittany Greenslade (@BrittAtGlobal) March 12, 2019

The report said families like Tina’s “struggle to find resources, and desperately needed publicly-funded services are too-frequently unavailable, unresponsive, or ineffective.

“Not enough has changed since Tina died in 2014,” said Penrose.

WATCH: Manitoba child advocate says report won’t solve the problem, only action will

Read the full report below.

The Winnipeg Police Service issued a response to the report Tuesday, saying they met with Chief and Council of Sagkeeng First Nation in the weeks following the Cormier trial to share information about the case and show their deep motivation toward finding justice for Tina.

“The Service welcomes the Manitoba Advocate for Children and Youth’s detailed findings and recommendations. We will continue to build on the relationships we have already established in the community, and continue to collaborate with our partner agencies to make Winnipeg a safe place for youth,” WPS said in a written statement.

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This morning, in Sagkeeng First Nation, we released our report on Tina Fontaine. Tina might always be known for the tragic way in which she died, but it is her life that is an important story worth knowing. Read the full report here: https://t.co/NT47dZpP4A pic.twitter.com/vej75qUvwq — Manitoba Advocate for Children and Youth (@MB_Advocate) March 12, 2019

A drum circle during the ceremony and prayer before the release of the Tina Fontaine report. Brittany Greenslade/Global News

-With files from the Canadian Press

The five recommendations in more detail

Manitoba Education and Training ensure its recently established Commission on Kindergarten to Grade 12 Education review the measurement of and response to absenteeism across Manitoba. It is further recommended that the Commission review the use of out-of-school suspensions and expulsions, with the goal of developing a province-wide strategy to limit, reduce, and phase-out exclusionary practices, except in situations of imminent safety risk to students and staff. This review and strategy should provide evidence-informed practices that are in line with the best interests of the child and respect the right to education for children and youth. Manitoba Health, Seniors and Active Living expedite the public release of a clear implementation plan to address the child and youth-specific recommendations contained in the report on Improving Access and Coordination of Mental Health and Addiction Services: A Provincial Strategy for all Manitobans (“Virgo Report”). Manitoba Justice evaluate the continuum of Victim Support Services for children and develop quality control measures to ensure that services are child-centred and provided in a timely manner. Manitoba government, through its Deputy Ministers of Health and Social Policy and Priorities (DMHSPP) committee, work with the government’s Legislation and Strategic Policy Branch to analyse the province of Alberta’s Protection of Sexually Exploited Children Act and Alberta’s Drug-Endangered Children Act to determine how safe and secure treatment facilities can be introduced in Manitoba. It is further recommended that the DMHSPP committee develop a plan to ensure the continuum of services for children and youth includes safe, secure, home-like settings for treatment and programming when children and youth are at imminent risk of harm or death. Manitoba Families, in consultation with other government departments and relevant stakeholders, create a new protocol to ensure that response plans are created for missing youth in general, and sexually exploited youth in particular who are at risk of imminent harm.