A new report released Tuesday found that the death of an 8-year-old girl in Border Patrol custody was “preventable,” citing shortcomings of the agency’s medical protocols.

Anadith Danay Reyes Alvarez, an 8-year-old girl from Panama, died in U.S. custody on May 17 in Harlingen, Texas. According to the newly released report, her death was a “preventable tragedy that resulted from a series of failures in the [Customs and Border Protection’s] medical and custodial systems for children.”

An internal investigation had previously found that Border Patrol medical staff declined to review the medical file of Alvarez, who had a chronic heart condition and sickle cell anemia. The day Alvarez died, a nurse practitioner declined to review the documents about the girl and denied three to four requests from Alvarez’s mother for an ambulance.

“The failure to consult a physician or a local health facility for more extensive testing raises fundamental concerns regarding the ability of the CBP medical system to care appropriately for children at elevated medical risk,” the report states.

The report made public Tuesday was completed by an independent monitor that was working to ensure the agency was complying with the Flores settlement agreement, which is meant to work toward child welfare protections for those in immigration custody.

Alvarez’s mother told the Associated Press that she notified staff about her daughter’s health conditions when they crossed the border, but officials did not notify other staff when the family was taken to a second facility. After six days, Alvarez tested positive for the flu and had a temperature of 101.8 degrees, the report said that

The report noted that there was no documentation that the health provider who diagnosed Alvarez with the flu consulted an on-call physician or that a transfer to a local health facility was “contemplated.” The report said that on the day of her daughter’s death, Alvarez’s mother asked for her daughter to be transported to a local hospital because her condition was “deteriorating,” but no transfer was initiated.

The report said that an ambulance was called only after Alvarez had lost consciousness and suffered an apparent cardiac arrest.

“These failures occurred at multiple levels and should not be viewed as rare anomalies but rather as systemic weaknesses that if not remedied, are likely to result in future harm to children in CBP custody,” the report said.

The Hill has reached out to Customs and Border Patrol for comment.

The Associated Press contributed to this report.