According to Turpel-Lafond's investigation, the girl, whose identity is withheld, was physically, emotionally and sexually abused, and had cognitive difficulties that were never addressed.
She lived with a mentally unstable mother who heard voices telling her to "snap" her child's head, had been physically and emotionally abused in both her home and her community, and had likely been sexually abused by at least one older adult and by a peer.
In May 2011, the girl hanged herself in the yard of her grandparents' home on a rural B.C. First Nations reserve, which the report declined to identify.
Turpel-Lafond said the province's health, educational and child welfare systems failed the 14-year-old girl miserably.
"In the utter absence of any real support, this girl decided the best way to deal with the torment was to take her own life," Turpel-Lafond said Thursday in Victoria.
Neither the school nor the Ministry of Health did anything about her learning disabilities or her complaints of sexual abuse, and medical professionals who knew this girl was at risk never reported it, the report concluded.
It also notes the Ministry of Children and Family Development regional office in the girl's area was chaotic and chronically understaffed.
“MCFD needed to act and it didn’t,” Turpel-Lafond said in a written statement. “At a critical time, it decided not to investigate concerns on-reserve and vacated its duty to this child and others."
Turpel-Lafond noted that in the final few months of the girl's life the regional office had only one child protection worker, when it was supposed to have seven, and was stretched beyond capacity.
"The Ministry should never have accepted this situation. This should have gone to the highest office in the province and child safety should have prevailed," she said.
Turpel-Lafond also said the government must ensure children on reserves have the same level of services as those who live elsewhere in the province.
B.C. Minister of Children and Family Development Stephanie Cadieux said she shares the concerns raised in Turpel-Lafond's report and is making addressing them a priority
"I have made a directive within the ministry that we will focus on delivering better support and services to aboriginal children and families."
Cadieux also said she is also reaching out to her federal counterpart to identify strategies to improve those services.