CONCORD, N.H. — A watchdog report based on a review of child fatalities calls on New Hampshire’s child protection agency to address systemic problems, including an outdated filing system, strained relationships with other agencies and internal biases among staff members.

The Office of the Child Advocate was created in 2017 as part of a larger effort to reform the state’s Division of Children, Youth and Families, which has been under scrutiny since two toddlers were killed in 2014 and 2015. It released a report this week based on a months-long review of six cases — five child deaths and the death of a parent — that focused not on the actions of particular individuals, but rather the environment in which they occurred.

“We used the same science now common in safety-critical industries like aviation and nuclear power to examine influences on case decision-making so we can understand when and how we can prevent tragedies,” Child Advocate Moira O’Neill said in a statement. “Child safety is equally as important as that of airplane passengers.”

The goal is to shift from “blame and shame” to system accountability, said O’Neill, who said recent criticism of the Manchester Police Department following a toddler’s death due to a cocaine overdose reflects misguided logic that “demands a culprit to make everything better.”

“Yes, police should call the Division for Children, Youth and Families when children are in harm’s way. However, DCYF should call police, too, and neighbors should call them both,” she wrote in the report. “As a community, we all carry responsibility for the safety and wellbeing of children. That includes ensuring well-resourced and effective prevention programs are available to families, and for when families struggle, child protective services that are equipped to intervene and ensure children are safe.”

The report identifies 10 themes that affect decision making at DCYF, including insufficient technology and difficult relationships with police, medical providers and substance abuse treatment providers. Accessing case history in the statewide child welfare information system is cumbersome and time-consuming, and a substantial amount of information is available only in paper form. On the relationship front, some staff described collaborative relationships with police while others described barriers to timely information sharing. For example, in one case, police responding to a home where a child had died did not notify DCYF of the child’s death or the presence of a sibling.

The report also described weary child protection workers who used the insensitive term “frequent fliers” to describe some families, and others who showed a bias toward immediate safety, resulting in cases being closed without assessing the potential for long-term stability. For example, a parent agreed to have her children live with a grandparent for a week, but there was no account of who would provide care after that.

In response, DCYF officials said the agency has embraced the same “science safety” used in the review in its own review of fatalities since 2017 and is currently revamping its review process, hiring a clinician to support staff and “mitigate their exposure to secondary trauma.” Nothing that the report was based on information from about a dozen DCYF staff, they also urged the child advocate to broaden her work to include more voices inside and outside the agency.

“DCYF is an important stakeholder in the broader child welfare system,” division officials said in a statement. “As the OCA acknowledges in the opening paragraphs of her report, child safety is a collective responsibility.”

The division also emphasized that the report raises several long-standing issues that are already being addressed, and described success in filling 21 of 27 recently-funded child protection worker positions.

More staff will help, but greater change is needed, the report states.

“Functioning for more than a decade with inadequate staffing appears to have established a culture of inadequacy that will need deep training, supervision and support to shift to a higher quality of service,” the report states.