ST. JOHN'S, N.L. -- She was 12, and seeking an abortion after being sexually assaulted and impregnated by her stepfather.

A report released Wednesday found Newfoundland and Labrador's child protection system responded inadequately to her case, and missed opportunities to intervene.

It took two more years, and a second abortion, before the girl told authorities in another province about the abuse, according to the report from the province's child and youth advocate.

"It was really shocking and it was saddening to see that this could happen to this little girl of 12 years old," said Jacqueline Lake Kavanagh.

Kavanagh says questions weren't asked, risk wasn't assessed, and consents were not appropriately obtained when the girl sought and ultimately obtained an abortion after saying she had become pregnant through consensual sex with her teenaged boyfriend.

"She received inadequate screening and assessments, which potentially enabled the sexual abuse of the child to continue," Kavanagh wrote.

"Had appropriate measures been taken when this child presented to terminate her pregnancy, or when child protection concerns were reported, the abuse may potentially have been detected and stopped."

The report said the family lived in Newfoundland and Labrador for about five months before moving to another province, where the girl told authorities two years later that she had repeatedly been sexually assaulted by her stepfather over a period of 26 months, resulting in two abortions.

The stepfather pleaded guilty in the case and to other offences including sexual assault on other individuals, and was sentenced to 16 years in prison.

The report says that shortly after arriving in Newfoundland and Labrador, the stepfather took the girl to a Planned Parenthood medical clinic seeking an abortion.

The man claimed to be the girl's biological father even though he wasn't -- the girl's mother lived outside the province and wasn't involved.

The report says although the girl said she had consensual sex with her boyfriend, questions were't asked about his age and the stepfather's guardianship status wasn't verified.

The child was referred to the Eastern Health Authority for an abortion where again, age-appropriate screening and counselling services weren't offered.

"The surgery was performed despite two sections of the consent form being incomplete, one of which included the legal capacity of the stepfather to sign for consent," the report states.

The child was discharged from the hospital with her stepfather with no further followup.

The report says officials with the Department of Children, Seniors and Social Development (CSSD) became involved a month later, after multiple protection referrals, including one that alleged the stepfather had physically abused the 12-year-old and one of her siblings.

Although the CSSD conducted some followup interviews, the child's grandmother and stepfather eventually became unco-operative, with the stepfather claiming harassment and the grandmother refusing to allow the children to be interviewed.

The family moved out of the province after four months of sporadic contact with authorities.

"Essentially she was a little girl going through an adult health care system and the responses really hadn't been set up and tailored to the needs of the child," Kavanagh said. "There's a red flag that should go up when a 12-year-old girl comes in pregnant."

The report says the province's health care system needs better co-ordination of services, while health care professionals need better knowledge of child protection legislation and the CSSD needs "appropriate protective intervention and follow up."

"Work together, find out who your resources are, develop your training programs or whatever methodology that you are going to use and share it," said Kavanagh.

Noni Classen, director of education at the Canadian Centre for Child Protection in Winnipeg, said in light of the report, child protection systems across the country could stand to revisit how they deal with young children in similar circumstances.

She said if there aren't specific protocols in place, there need to be.

"Right at 12 there should be an automatic response to engage in an inquiry into what's going on," Classen said.