MONTREAL — A coroner says Quebec's child protection services failed a young girl from Granby, Que., whose death in 2019 galvanized the province into reforming the system.

Géhane Kamel's report says institutions that were supposed to protect the seven-year-old — including youth services, the health network and the school system — did not co-ordinate a proper response to save her.

Her killing in 2019 led to a high-profile public inquiry and triggered reforms to the youth protection system.

The girl was found in cardiorespiratory arrest with adhesive tape covering part of her body, including her mouth, and she died in hospital from asphyxiation.

Among Kamel's dozen recommendations is the need to improve communication between government departments, and to put children at the centre of all

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