The report is in on how the case of Haleigh Poutre–the girl who was victimized by her family, then by authorities who decided she should be killed, only days before she overruled the decision– was handled:

Twelve-year-old Haleigh Poutre was nearly killed by chronic child abuse and then almost died from a premature decision to remove life support, because flawed or insufficient information was given to the state agencies, medical centers, and court systems that were supposed to protect her, a governor’s investigative panel said yesterday.

A system-wide disaster is how the governor’s statement reads.