Child services agencies are underfunded and overworked. That was one immediate reaction from several welfare advocacy groups to the Colorado Department of Health Services' official review of the tragic death by starvation of 7-year-old Chandler Grafner in May.

Yet we read the report, too, and could find little evidence that either factor - even assuming each is true - was remotely a cause in Grafner's cruel fate.

To the extent his death could have been prevented by timely intervention, the culprit was - in one critical instance, for example - an incorrect assumption as to which public agency should follow up on a particularly bright red flag.

And until that time, it is not clear that even an overstaffed agency would have discovered Chandler's hellish existence in time to save him.

Yet spokespersons for the Colorado Association of Family and Children's Agencies and the Colorado Children's Campaign each have suggested that somehow bigger budgets and larger staffs at social service agencies could have prevented the tragedy. County and state departments lack the money to track abuse cases and share information across jurisdictions, they say, so some can fall through the cracks.

Maybe some do, but that's not the story we read in the state's review of Chandler's death. It says that had counties followed current procedures more diligently, case workers might have saved him from the combination of abuse and neglect that eventually led to his death and to first-degree murder charges being lodged against Jon Phillips, Chandler's legal guardian, and Sarah Berry, Phillips' common-law wife.

The report did recommend several policy changes, which would mainly amount to doing a better job following up on allegations of abuse. But from what we can tell, no bump in any budget would have stopped the adults who were entrusted with Chandler's care from allegedly locking him in a linen closet and letting him slowly starve to death.

For at least the final 32 months of his brief life, Chandler was shuffled from one place to another, placed at times in the custody ("care" seems inappropriate) of his mother, his grandmother and finally Phillips (his mother's boyfriend) and Berry.

The review chronicles 14 contacts involving Chandler's guardians and various social service, education and law enforcement agencies between Oct. 4, 2004, and May 6 of this year, when he died. Agencies in three counties - Jefferson, Arapahoe and Denver - were involved.

Several instances involved allegations of abuse and neglect. Yet in only one instance were charges filed - and then, Chandler's mother, Christina, pleaded guilty to a charge of reckless endangerment and received one year probation.

At times, child welfare officials completely lost track of the whereabouts of Chandler, his brother and the adults who should have cared for them.

Clearly, better agency follow-up was in order. That said, we see only one time more aggressive intervention was almost certainly called for that had a chance to save Chandler.

In early March, he stopped attending kindergarten at Holm Elementary School in Denver. Berry, who had worked as a teacher's assistant at the school, reportedly told teachers that Chandler was going to be home-schooled.

That should have immediately raised alarms. A few weeks earlier, as it happens, school officials found bruises on Chandler, who said Phillips had struck him in the shower. The school notified the Denver Department of Human Services and a police investigation even followed. However, it led to no charges.

The school should have told Denver Human Services of Chandler's absences right away. Instead, it waited until April 17, three weeks before Chandler died. At that point, unfortunately, the agency simply noted that there were no allegations of neglect or abuse in the referral and that Chandler's case file remained "open" in Jeffco. It made no mention of the school's report of Chandler's alleged abuse in January. It failed to connect the dots.

We're not trying to point fingers at social workers and bureaucrats, all of whom are as horrified as we are by Chandler's death. But it is simply too pat to always cite budgets and staffing as the reason for institutional failure. That suggests that no one can be held accountable, even when someone incontestably is at fault.