Poor communication among several District agencies led to tragic mistakes in the case of Relisha Rudd, with officials failing to act because they wrongly assumed others had, a city report found Tuesday.

The report is the city’s first public accounting of 8-year-old Relisha’s contact with agencies before she vanished in March with Kahlil Tatum, a 51-year-old janitor at the shelter where she lived.

But even with the shortcomings, the report says that “no justifiable government actions would have prevented Relisha’s tragic disappearance.” The 12-page report also says “there was no recent assessment of [Relisha’s] parents’ capacity or of the family’s overall functioning.”

(Read: Report predicts another surge in homeless families in D.C. this winter)

Child-welfare advocates and D.C. Council member Jim Graham, head of the committee tasked with overseeing the shelter, blasted the report, saying that the city wrongly concluded that nothing could have saved Relisha, who remains missing.

Relisha Rudd

This is a sorry “and terribly tragic tale of government failure,” Graham (D-Ward 1) said in an e-mail. “I am totally baffled by the report’s conclusion that ‘no justifiable government actions would have prevented Relisha’s tragic disappearance.’ I think it is now obvious that much more could have been done to protect this vulnerable child.”

On Feb. 26, Relisha’s mother allowed Tatum to take the girl home with him. Authorities first realized she was missing March 19, when a school social worker tried to confront the janitor at the crowded emergency shelter on the grounds of the old D.C. General Hospital. Tatum’s wife was found that day, fatally shot in the head in a Prince George’s County motel. Police said Tatum and Relisha were last seen March 1, and the next day, police said he bought 42-gallon trash bags and was seen at Kenilworth Park and Aquatic Gardens. His body was found there March 31.

On Tuesday, child-welfare advocates asked why, if nothing could have saved Relisha, the public should have confidence that it can’t happen again.

Relisha’s disappearance prompted an exhaustive search by D.C. police and sparked public outrage at how a young girl could be abducted by an employee of a D.C.-run shelter and be missing for more than two weeks before anyone in authority noticed.

“Given that so many agencies had eyes on this child and her family as well as the breadth of the report’s recommendations, it is difficult to accept that this type of tragedy could not have been prevented,” said Jamila Larson, head of the Homeless Children’s Playtime Project, which provides volunteer services at the shelter and is working to build a playground there. The many problems the task force found “do not make a tragic outcome inevitable. Rather, it makes our responsibility greater.”

Abigail Smith, deputy mayor for education, defended the city agencies and the Community Partnership for the Prevention of Homelessness, the nonprofit contractor that runs the shelter under a $13 million contract with the city. A call to Sue Marshall, the nonprofit’s executive director, was directed to the city’s Department of Human Services.

Deborah Carroll, head of the department, defended the Community Partnership and the operation of the shelter. “We have a tremendous amount of confidence in the Community Partnership,” Carroll said. “It is probably one of the best-run shelters in the country. The physical layout may not be what we want it to be, the size may not be what we want it to be, but the shelter itself is very well-run.”

The report says that by the end of this month, Mayor Vincent C. Gray’s administration will submit legislation for a plan on how to shift from the city’s one main shelter to smaller neighborhood ones.

The officials described the failures that helped create an unavoidable tragedy as an extraordinary confluence of circumstances coupled with the family’s deception about whom Relisha was with and where she was staying. Even had reforms recommended in the report been in place, they said, Relisha might still have gone missing.

“The recommendations are very important,” said Judith Meltzer, deputy director of the Center for the Study of Social Policy and a member of the review team, which was assembled by the mayor to look into how the city handled Relisha’s case. “They point out places where for the future things could be improved. The goal of any government is to protect children and identify places where the safety net has wrinkles.”

Meltzer, who also serves as the court-appointed monitor of the city’s child-welfare agency, said the girl’s mother had thwarted routine steps to check on Relisha’s well-being. She allowed her daughter to stay with Tatum, sent the school fake excuse notes signed “Dr. Tatum” and declined to file a missing-person report when police finally got involved.

“This was, in some ways, a unique case in terms of the extent of misinformation that was provided,” Meltzer said. Of the police’s belief that Tatum killed Relisha before he took his own life in a shed in Kenilworth Aquatic Gardens and possibly buried her in Kenilworth Gardens, Meltzer said, “There is no accounting for evil action.”

Meltzer said the most important finding is that the emergency shelter at the old D.C. General Hospital, which houses as many as 800 people in dangerous, dirty and insect-infested conditions, “is not a place to raise children. The city needs to take aggressive action to come up alternatives for homeless families.”

The report — released six months after Relisha was last seen alive on March 1 — makes clear that one of the District’s strongest lines of defense against child abuse and neglect crumbled before the girl disappeared. The District has a long-standing mandate that social workers, doctors and other professionals who suspect mistreatment of children report those concerns to the Child and Family Services Agency.

But the report says there were “several instances” in which providers “expressed concern about the safety and well-being of the children but failed to act.”

According to an unredacted version of the report described to The Washington Post, Gray’s administration also found that there was “limited intervention” by city agencies to address allegations of domestic abuse between Relisha’s mother and her boyfriend or their alleged substance abuse.

The report redacts the explanation given by those providers in order to conceal the type of D.C. service the family was receiving, but city officials who spoke on the condition of anonymity said the providers’ rationale was they understood that CFSA staff was already aware of problems and working with the family. Officials said that in essence, some social workers thought others had acted, when they hadn’t.

Child-welfare advocates blasted that explanation as violating the most basic responsibility and blunting the usefulness of the law. Only if everyone reports their concerns, they said, do the number of warnings serve as a barometer for the potential depth of dysfunction.

Smith, the deputy mayor, said that none of the professionals who failed to make a report was singled out for discipline or firing. The report says staff members at an unnamed agency would receive additional annual training to comply with the mandated reporting law.

Complicating efforts, D.C. officials said, was that Relisha’s mother frequently allowed her daughter to spent time with Tatum, and on Feb. 26 she allowed her daughter to accompany him home. Officials at her school, Payne Elementary, grew worried after her absences — including ones that were excused — mounted to more than 30 days, including those signed by the fake “Dr. Tatum.”

The District requires the school system to notify the welfare agency within two business days after a student’s 10th unexcused absence. That was not done in Relisha’s case, although officials said the wording of the rule allows for many steps and exceptions, and in this case, school workers were in contact with Relisha’s mother to get the girl back to class. The report recommends that this notification requirement be more stringently enforced.

Melissa Salmanowitz, spokeswoman for the school system, said the report is helpful in pointing out places to “improve our efforts” but also noted that school staff took “steps beyond standard protocol” that led to Relisha being discovered missing. A social worker, concerned by the signature on absence slips, pressed to meet Tatum at the homeless shelter. He didn’t show up, and that got police involved for the first time. By then, it was March 19, more that two weeks after Relisha’s mother allowed her daughter to go home with Tatum.