Former childcare worker Ashley Paul Griffith committed hundreds of sexual offences against young children for more than two decades before finally being exposed and sentenced to life in prison.
The "harrowing" Queensland Child Death Review Board report on Monday found repeated red flags and warning signs had been raised over Griffith but not shared across two states.
"The offending could — and should — have been detected and disrupted earlier," the report found.
"Sufficient concerns were recorded to have enabled earlier intervention ... instead, information remained siloed, and the warning signs were never fully connected."
The report ordered by the state government in January raised critical questions surrounding the identification, prevention and response to child abuse in Queensland, using Griffith as a case study.
The review - titled "In Plain Sight" - made 28 recommendations to improve laws and policies across early childhood education, police and the blue card system.
Parents, children and staff repeatedly raised legitimate concerns over Griffith but he was only caught when he was detected uploading digital images.
"The effect is that risks are routinely identified but remain unmitigated, while families and victim-survivors are left without redress until catastrophic harm is undeniable," the report found.
"These findings point to the need for a stronger whole-of-system approach, underpinned by proactive detection, co-ordinated responses, investment in prevention, and sustained recovery pathways."
Premier David Crisafulli said the report made for "harrowing and disturbing reading" and demanded a swift response.
"It'll send shivers up the spine of every Queensland parent, but it is a call for action, and action is what we will be delivering," he said.
"No system will ever be bulletproof, but we can do so much better."
The Queensland government had already confirmed it would introduce a reportable conduct scheme in 2026, a recommendation of the 2017 Royal Commission into Institutional Responses to Child Sexual Abuse.
It will require organisations to report and investigate allegations or convictions of child abuse or misconduct made about their workers and volunteers.
"I express our complete, utter sympathy and sorrow and reflect on some of the comments from the commissioner," Mr Crisafulli said.
"It must be the most harrowing experience for any family and from their heartache, change will come, and change must come in Queensland."
Griffith committed more than 300 offences, including ongoing sexual abuse and making child exploitation material, against 65 victims aged one to nine beginning in 2003, targeting childcare centres.
He was sentenced to life in prison last year but is appealing the sentence.
Griffith is separately accused of abusing at least two dozen children in NSW and in Italy.
Queensland's Family and Child Commissioner Luke Twyford's report included an open letter to victims.
"I have come to understand the depth of the betrayal that you and your families have endured: the deception, the silence, the failure of people and systems that should have protected you," he said.
"I cannot undo what was done. I cannot take away the pain, nor fill the spaces left by broken trust, broken relationships, or hopes that feel lost, but I can say this plainly: I believe you."
Mr Twyford said in the heartfelt message that he could see the price paid by not only the victims but also the parents who placed their trust in systems that "utterly failed them".
"Instead, you were met with betrayal and harm," he wrote.
"I am committed to pursuing the changes needed to ensure that no parent or child experiences this kind of harm again."
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