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An Alberta judge says the death of a foster boy from abuse was a direct result of the failure of provincial child welfare to deal with his case properly.

Kawliga Potts was three years old when he died in 2007 of extensive head trauma in Edmonton. His foster parent, Lily Choy, was later sentenced to eight years in prison for manslaughter.

A fatality inquiry report says Ms. Choy's application to be a foster parent wasn't properly completed or reviewed and case workers were aware of abuse, but failed to take action.

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"Kawliga Potts's death was a direct result of the fundamental failure of everyone connected with this child to do their jobs," provincial court judge Ferne LeReverend wrote in her report released Friday.

During Ms. Choy's trial, the Crown argued that the boy's death was a case of "near murder." Court heard that Ms. Choy hit the boy, denied him food and left him wearing only a diaper in an unheated garage.

The report said the Indigenous boy had developmental problems and may have suffered from fetal alcohol syndrome.

Justice LeReverend said Ms. Choy, a single parent with two children of her own and three other foster children, was not qualified to care for Kawliga.

When evidence of abuse came to light, no one reported it to the child advocate or police, she said.

"Evidence of abuse was present. 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 Potts."

Justice LeReverend recommends the province disclose the names of children who die in care and establish a committee to investigate the deaths of all such children. She also recommends the province expand the mandate of the child and youth advocate to act on behalf of families in the child-welfare system.

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Justice LeReverend said police should be notified immediately when staff suspect criminal activity and the government should provide whistle-blower protection for families and officials.

Health Minister Sarah Hoffman said the government is reviewing the recommendations. She said the system has substantially improved since Kawliga's death.

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