Child welfare agencies in Pennsylvania missed one "red flag" after another in the case of a teenager who endured years of physical, mental and sexual abuse before her 2016 rape and murder, according to a report released Monday.

Investigators reviewed 14-year-old Grace Packer's frequent interactions with an "overwhelmed" child welfare system, and concluded that caseworkers had plenty of opportunity to protect her but failed to do so.

"It's hard not to be totally shattered on behalf of Grace that this was her life," Cathleen Palm, founder of the Center for Children's Justice, a nonprofit advocacy group in Pennsylvania, said after reviewing the findings. "It is absolutely clear that there was point after point after point that her life could have changed. It could have changed."

The Pennsylvania Department of Human Services released the heavily redacted, 34-page report three days after Grace's adoptive mother, Sara Packer, pleaded guilty to first-degree murder and was sentenced to life without parole for plotting her brutal death. Sara Packer's boyfriend, Jacob Sullivan — who raped and strangled Grace while her mother watched — was sentenced to death last week.

The report's timeline spans nearly the entirety of Grace's 14 years, detailing her removal from her biological family, her subsequent placement with Sara Packer, and a multitude of reports of physical and sexual abuse throughout her life. The report describes a badly frayed social safety net in which information was not shared between jurisdictions, the services provided to Grace were ineffective, and clear warning signals about her safety were ignored or minimized.

"With multiple allegations/investigations over several years, it would seem that this case should have been thoroughly assessed for the safety of Grace ... and maintained as an open case for a longer period of time," the investigators wrote.

In 2007, Grace was adopted by Sara Packer — a county adoptions supervisor and foster mother who took in dozens of children over the years — and her then-husband, David Packer. The report noted that caseworkers allowed Grace to remain in the Packer home even after David Packer went to prison for sexually abusing Grace and a foster child, and Sara Packer acknowledged having sexual contact with a foster child.

Sara Packer, 44, told a jury last month that she hated Grace and wanted her dead. In July 2016, she and her boyfriend, Sullivan, took Grace to a vacant house about 50 miles (80 kilometers) north of Philadelphia. There, in a stifling attic, Packer and Sullivan gave the teenager what they intended to be a lethal overdose of medicine, and Sullivan raped her while Packer watched. The couple bound Grace with zip ties, stuffed a ball gag in her mouth and left her for dead.

Returning 12 hours later to find that she was still alive, Sullivan strangled Grace while Packer held her hand. They stored the body in cat litter for several months before dismembering her remains and discarding them in a wooded area.

The state human services agency, three Pennsylvania counties (Berks, Lehigh and Montgomery), and Burke County, North Carolina, were involved in Grace's case over the years. It's not clear whether anyone was suspended, fired or otherwise disciplined as a result of her murder.

"We are deeply affected by the terrible tragedy that befell Grace Packer. We place the safety of every child at the highest priority. All reports to the county are thoroughly screened and our response is in accordance with the law," said Montgomery County spokesman John Corcoran. "As a result of this report, Montgomery County is evaluating and updating screening protocol to include review of prior referrals and review of existing information in any other county when possible."

Kerry Freidl, an assistant solicitor with Lehigh County, said the county is reviewing the state report. He declined to comment further.

Officials from other agencies did not return calls and emails for comment Monday.

Palm, with the Center for Children's Justice, said the failings cited in the report continue to permeate Pennsylvania's child welfare system.

"If it's not different today, then there is another Grace Packer out there that we just haven't met," she said. "And that's my worry."