Many years ago I was in a high level administrative position at OCS (then DFYS) and before that I had some experience as an Assistant AG in a rural hub. Even then the complexities of federal funding required extensive administrative staff time, with no benefit other than funding. There was - and is - a need for extensive documentation for due process and for good case analysis. But as with doctors,  the paperwork demands get in the way of direct patient (family/child) care. Combine that with cultural complexities, staff turnover and burnout, inadequate resources for placement, therapy, and treatment, increasing levels of family dysfunction, variations in subjective judgment, and weaknesses in management at several levels, and you've got a perfect storm. But as always, reports and investigations will consume time and resources but are not likely to bring real improvement, leaving OCS, its critics, and the public unsatisfied, and thus children harmed.