WINNIPEG - A review into the death of a two-year-old boy in the care of a Manitoba aboriginal child welfare agency has revealed "serious shortfalls" that contributed to the tragedy, says an agency official. "We definitely failed this child," said Elsie Flette, executive director for the First Nations of Southern Manitoba Child and Family Services Authority. Gage Guimond died a year ago after falling down the stairs. Police, who believe Gage was the victim of prolonged physical abuse, have charged his great-aunt, Shirley Guimond, with manslaughter. The review - which was edited before its public release Thursday due to strict laws surrounding child welfare cases - outlines a troubling series of events leading up to the boy's death. Flette, who released the review, said it identified "serious shortfalls within" the Sagkeeng Child and Family Services, the agency tasked with taking care of the little boy. "That led to decisions and actions that were made and that were taken that contributed to the death of Gage Guimond," she said. In his short life, the toddler was shuffled to at least four different homes. Gage was transferred to a family member from an aboriginal foster home because of a rocky relationship between the foster parents and Sagkeeng staff. When the boy was removed from that relative's home, social workers initially did not do a criminal record check on his caregiver or conduct a proper safety assessment, said Flette. The review said it was later determined the caregiver at that placement was not suitable because of that person's involvement in what Flette would only describe as a "high-risk criminal offence." Gage was then moved to the home of his great-aunt, who was convicted in'87 for assault - but that wouldn't have stopped social workers from placing the little boy in her care, Flette said. "It was an old conviction," said Flette. "We have... people who have turned their lives around." While the agency checked Guimond's criminal background, Flette said the review found the assessment of the aunt's home was not properly done. "Had they ... they would not have made that placement," she said. The week Gage died, most of the agency's staff were on a retreat in Calgary, leaving one supervisor and three workers to handle cases of more than 200 children. Internally, the agency had numerous management problems, including nepotism and low morale, the review found. Sagkeeng's executive director and another staff member were asked to resign. The staff member's supervisor was also demoted. He then left the agency. Flette said staff are working on the 88 recommendations outlined in the review.