Christine Delisle-Brennan identified several shortcomings in the way the province dealt with the child, who died seven months after authorities were alerted to concerns about their well-being.
Her report says there were problems with vague standards, poor communications, inadequate record keeping and heavy caseloads at the Department of Community Services.
"What emerged from our investigation might best be described as system fragmentation," Delisle-Brennan said in a statement. "In some instances, there were a series of disconnects, vague or non-existent standards and uncertainty of approach."
The report says the ombudsman's office decided not to name the child or family members because doing so would serve no purpose.
"Among other considerations, siblings of the child now have reached an age at which public attention could create more harm than good," the report says.
The report recommends the Justice Department create a team to examine all child deaths and serious injuries where government services are involved.
"Automatic investigations for such cases, usually involving a team representing several government departments, are common in several provinces," the report says.
A spokesman for the Justice Department said a committee will be set up to draft a response.
Vicki Wood, a spokeswoman for the Community Services Department, said staff will review the recommendations and there are plans to hold talks with the other departments mentioned in the report — Justice and Health.
"We view it with great seriousness in terms of the concerns that it raises," said Wood, who added that the departments have 30 days to respond to the report.
Wood challenged the suggestion there was poor communication between government agencies and departments.
"If you read (the report) carefully, you'll see that police and medical personnel worked hand-in-hand with staff as they were investigating — and that is our experience," she said. "But there is room for improvement."
The Community Services Department did conduct an internal review, but the results of such investigations are not made public. As well, Delisle-Brennan found some of the department's recommendations had not been implemented.
"This office believes that a more independent oversight mechanism is required to conduct child death reviews in Nova Scotia," the report says.
The child's age and sex were also not released, but the administrative review says the child died more than two years ago at home as the result of blunt abdominal trauma.
The mother of the child and the mother's partner were known to police, who were called to the home to investigate a domestic dispute seven months before the child died. That's when Community Services was first told about the child.
In all, the department received five referrals or complaints about the child's well-being, including two that prompted an investigation about three months before the child died.
"Multiple referrals and lengthy investigation periods can create confusion," the report says.
"It is unknown whether gaps between entries reflected inactivity on files or had any impact on the nature of responses. However, these concerns were increased by the fact that two investigation files remained open when the child died."
The report says the mother's partner was charged with manslaughter and acquitted.
The ombudsman's investigation did not turn up evidence of government wrongdoing nor anything to suggest government agents or public servants acted in "an uncaring or indifferent manner."
The ombudsman is also recommending the Community Services Department clarify its standards and work to reduce the caseloads, which remain slightly higher than the maximum.
The investigation also found sharing of information between health-care personnel and child protection staff was hampered by legislative requirements, the sensitive nature of health information and database differences.
"Throughout this investigation, this office observed ... health-care professionals invoke confidentiality as a barrier to sharing information," the report says.
Follow @NovaMac on Twitter.