Saskatchewan's children's advocate says he's concerned about the quality of case work in child protection services and says inconsistency is especially problematic.

Bob Pringle commented Monday on the outcome of a coroner's inquest that finished last week in the death of Lee Bonneau, who was killed by an older child on a reserve.

Six-year-old Lee Bonneau was found with head injuries in a wooded area on the Kahkewistahaw reserve in 2013. He had last been seen walking with an older boy outside a recreation complex while his foster mother was playing bingo.

On Friday, the jury released 19 recommendations, which ranged from improving mental health supports to funding a facility for children under 12 with complex needs.

Pringle determined in a report last year that the 10-year-old boy who killed Lee had behavioural issues and probably should not have been in the community unsupervised. Because he was under 12, he could not be charged under the Youth Criminal Justice Act.

Pringle said the inquest made it clear that agencies need to communicate better with each other and social workers are struggling under heavy work loads.

"We know that the (Ministry of Social Services) is in a situation where, when they take a child into care, they are not able to keep up with their case planning and their contact standards," he said.

The jury's recommendations were mainly directed towards the Ministry of Social Services and the Yorkton Tribal Council Child and Family Services. They included addressing communication shortfalls and revising the size of service centres for rural offices.

The jury also recommended that fetal alcohol syndrome, attention deficit hyperactivity disorder and mental health issues should be addressed as soon as they are identified in children.

Pringle said several witnesses who testified appeared to be absolving themselves of responsibility for children's welfare.

"There were some turning points there."

He said one example is that assessments weren't properly done to determine if Lee's father could offer him a suitable home.

Both children fell through the cracks, he said.

"In both cases the lack of identifying important risk factors are a concern."

Pringle said since the release of his report last year, both the Ministry of Social Services and Yorkton Tribal Council Child and Family Services have made important strides.

This includes improving training methods and quality assurance.

Social Services Minister Donna Harpauer said the government is reviewing the recommendations and will formally respond in two to three weeks.

"A lot of work has been done over the last two years," she said, adding that some of the recommendations from the coroner's inquest overlap with those of the children's advocate.

"It was so obvious in this particular issue that there was a communication breakdown from service providers."

The Yorkton Tribal Council Child and Family Services have since implemented an electronic database system, she added.

NDP social services critic David Forbes said he's "shocked and disappointed" by systemic problems.

"This is happening far too often here in Saskatchewan. We know between 2010 and 2013, 81 kids died in Saskatchewan care. Here we have a circumstance that really calls for immediate action," he said.

He said the recommendations around mental health and fetal alcohol syndrome are particularly important.

"We'd like to see this government bring forward protocols so that kids who are in need ... can access services right away. We can talk about jurisdictions later."