The third party review of DDHS policies and practices was sparked by a Call7 Investigation of the deaths of Chandler Grafner, Neveah Gallegos, Luz Valdez and Joslyn Asberry.

“These tragic situations have cumulatively weakened public confidence in the ability of the DDHS to protect children and put into question the effectiveness of Denver’s child protection practice,” the report found.

DDHS manager Roxane White, who is leaving the department next month for a foundation job, said the review will help protect children and she is proposing that it happen on a regular basis.

"I think it would be good policy for every county in the state to have an external review of their practice in an ongoing way and every few years to stop and do this," she said.

The report, which reflects many of the findings of a 10-month CALL7 Investigation, also found that there was tension and distrust between the courts and human services workers and that DDHS clients found the case workers unhelpful and unsupportive.

“The parents and youth the Review Team met expressed deep concern about the uncaring, judgmental and hostile caseworkers with whom they have had interactions,” the review found.

Denver Mayor John Hickenlooper said that disputes between the courts and social workers need to end.

"Courts and human services have the same goals," he said. "There is no reason why they absolutely shouldn't be able to work together."

The report also found that workers did not focus on what brought the case to DDHS attention in the first place or on reports of past family problems when assessing the risks to children.

There were also no clear guidelines to determine whether DDHS cases would be brought before a juvenile judge or be handled in a voluntary way within the human services department.

“There is a general perception among court personnel and law enforcement that the process for oversight and monitoring of voluntary agreements is not going well,” reviewers from the Annie E. Casey Foundation and Child Welfare League of America wrote.

DDHS has implemented a new assessment checklist that will have layers of review and oversight. The open cases will also be reviewed every 90 days.

They will train investigators to do background checks, responding to a CALL7 Investigation that found that workers were not checking city sex offender records in abuse and neglect cases.

CALL7 also found that caseworkers were not interviewing the alleged abusers in three cases and did not follow up on concerns by family members and teachers before the children died.

The department implemented a new policy last month to determine which cases went to court and will start tracking the outcomes of voluntary cases by the end of May.

"We've added quite a bit of structure to the process," White said. "We've done two rounds of that to make sure staff really understand what really needs to be done in risk and safety under the new changes."

DDHS officials previously said they would add 40 new case workers and will now add an additional 25 workers.