Bob Pringle released a report Tuesday renewing concerns about overcrowding and a lack of co-ordination to get children support services.
He said one solution is to require all foster homes in the province to be licensed, following the practice in Alberta, Manitoba and Ontario.
"Licensing provides accountability for both the Ministry of Social Services and for foster parents, improves public confidence, and helps ensure that the rights, interests and well-being of children are being respected," he wrote.
The report focuses on the care of a boy who died in a Saskatoon foster home in December 2009, a few days before his second birthday.
A support worker found the toddler dead in a playpen when she tried to wake him one morning. A medical examiner was unable to determine what caused his death and police ruled out foul play.
Pringle said that while the boy's death remains a mystery, an investigation into his short life — most of it spent in care —raises concerns.
By the time he was 15 months old, he had moved 11 times. When he died, he had been living in an emergency foster home with as many as 14 other children for nine months.
Foster homes in the province can have up to four children but, with permission, this one was given additional support workers and its capacity was increased to 12.
Children were also supposed to stay a maximum of two weeks in the home, but many stayed beyond that.
At one point before the boy died, the foster mother in charge of the home had warned social workers she was "burning out."
There were also concerns that the boy was developmentally delayed — he was small for his size, couldn't yet talk and because his mother drank while she was pregnant it was suspected he had fetal alcohol syndrome.
Pringle said public health nurses, doctors, an early childhood psychologist and a foster parent all raised the issue of his delays, but not enough followup was done by social workers. Although referrals were made, the boy was never assessed.
"His needs and best interests were lost as he moved between caregivers, and the many concerns raised about his developmental delays were lost through inadequate case management, inaccurate documentation and a lack of co-ordination of services," Pringle wrote.
The child "appeared to be on the margins rather than at the centre of the systems providing him with services ... (He) did not get the good start to which all are children are entitled."
A former children's advocate in the province, Marvin Bernstein, released a scathing report the year the boy died, describing how Saskatoon's foster homes were in crisis.
Figures showed homes in the city were more overcrowded than anywhere else in the country. At one time, as many as 21 children were living in a single foster home.
A psychologist in that report compared one home in the city she visited to a "puppy mill."
The province reacted by promising to expand group homes and increase foster parent recruiting.
In 2011, a review into the boy's death also came up with 16 recommendations for improvements. Fourteen of those, which included stopping more high-capacity foster homes from opening, have been since implemented, said Pringle.
While much has changed in Saskatchewan, he added, more needs to be done.
He made seven recommendations in his report, including one for the province to amend its Child and Family Services Act so all foster homes must be licensed.
He also asked that the province conduct a study into the number of times children are moved while in care.
"Overcrowding in foster homes can overwhelm a caregiver’s ability to keep children safe and provide the kind of nurturing environment they need to develop optimally."
Social Services Minister Donna Harpauer told reporters that her department will do an analysis of child movements. As well, legislation is currently under review about possible changes, which could include licensing foster homes.
But Harpauer said there are already tough controls in place, and requiring homes to have licences may not necessary.
"One thing I don't want to see is licensing just for the sake of a licence. It's got to have regulations that indeed make it meaningful."
— By Chris Purdy in Edmonton