13 children died while in care or known to social services last year
Six of the 13 children either in state care or known to social services who died last year were babies.
One of the deaths involved a suicide.
The annual report of the National Review Panel shows one child died as a result of an accident, eight from natural causes and one of an unknown cause.
Maternal drug abuse was associated with four of the baby deaths although not identified as a cause.
One of the children was in care and another had left for aftercare. Social work services were in contact with 11 others.
The independent review of 12 of the deaths showed evidence of good and sub-standard practice.
Review chairwoman Helen Buckley said that good practice was evident in the two cases where children died from serious illnesses.
There were examples of consistent child-centred work and excellent inter-agency cooperation.
However, in other instances they found the early responses after the child was referred to social work departments were slow and fragmented.
Some of the reports of concern about the children were given a less serious classification than was warranted.
This was particularly the case in those where children were at risk from their own behaviour or from the effect of living in adverse circumstances.
Lack of adequate assessment existed in some instances. Deficits were highlighted in mental health services and care for children with autism.
Of the six other deaths, one boy and two girls were aged 11 to 16. They also included a boy and girl aged 17 and 20 years. Another tragedy involved a young girl.
The review pointed out that in one case where a young person had been accused of sexual assault on another person, the social worker department should have acted differently. Social workers assessed the alleged victim .
However, it later concluded that the delay in providing a response to the accused went against his best interests.
The review calls for more active follow-up in cases where child protection thresholds have not been reached.
The fact parents were not considered liable for the difficulties being experienced by their children should not dilute the level of concern held by Tusla for their safety.
It found that, as in previous years, children could be placed in the wrong section. They were put in the "welfare" section of Tusla rather than the "child protection" category when risks to them were evident.
The review team said the classification of welfare was made if no parental omission was deemed to exist, regardless of the dangers which the young person was facing often through their own behaviour.
There should also have been consideration given to the impact of earlier adverse events on this, such as parental violence or addiction.
The report highlighted the lack of an out-of-hours service in rural areas, which has since been remedied.
Dr Buckley said: "On behalf of the panel, I wish to extend my sincere sympathies to families, friends and all those affected by the deaths of the children."