But provincial court Judge Bart Rosborough says that still might not have prevented the one-year-old girl's death.
The judge notes that the foster parents weren't informed that the girl had been treated for respiratory problems, including pneumonia.
The baby, who is not identified, died of pneumonia in March 2009 while in the care of an agency that provides child-welfare services to the Samson Cree Nation south of Edmonton.
The child had been sick, but her foster family assumed it wasn't serious.
Her caregivers didn't seek medical attention until she was discovered not breathing in her crib.
Rosborough acknowledges in his report that a previous case of pneumonia doesn't make a person more likely to get pneumonia again. He also notes that the foster parents should have realized earlier that she was seriously ill and should have been better trained.
Still, he writes, failure to inform the foster family of the girl's medical information was the factor that put her most at risk.
"Failure to observe this requirement should trigger an escalating series of notifications up to the director level," Rosborough writes in his report, which was released Thursday.
It says the girl's birth parents had serious addictions and the mother voluntarily surrendered custody to child-welfare officials after bringing the baby to hospital with pneumonia in December 2008.
The mother had been "diligent" in seeking medical treatment for her daughter, who "was noted to cry a great deal and would experience 'wheezing' or mild difficulty with her breathing from time to time."
When the Kasohkowew Child Wellness Society received information that the mother was using cocaine and was pregnant with another child, the girl was transferred into the care of a woman who worked for the society, and her husband.
Rosborough says that should have been considered a conflict of interest and should not be repeated.
"It is often natural to repose trust and confidence in those with whom one works. Standards can be relaxed and safeguards not observed. That may well have occurred in this case."
Rosborough also notes there was testimony during the inquiry that the Kasohkowew society lacked adequate resources and had management troubles. There was testimony that staff had used agency funds for cultural activities and to attend out-of-country training.
Rosborough says the inquiry was not the proper place to investigate management issues at Kasohkowew, but he adds he was convinced a review is necessary.
He also says the province should investigate what he calls the "significant disparity" in the level of funding provided for children off and on reserves.