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The Massachusetts child protection system failed to prioritize the needs of a 5-year-old New Hampshire girl who vanished in 2019after her father was awarded custody, according to a much-anticipated independent review released Wednesday.

Harmony Montgomery suffered from a ripple effect of “miscalculations of risk and unequal weight placed on parents’ rights versus a child’s wellbeing,” said Maria Mossaides, head of Massachusetts’ Office of the Child Advocate.

“We do not know Harmony Montgomery’s ultimate fate, and unfortunately, we may never,” Mossaides said at a news conference. “But we do know that this beautiful young child experienced many tragedies in her short life, and that by not putting her and her needs first, our system ultimately failed her.”

The review was promised earlier this year, not long after police in Manchester, New Hampshire, learned the child had been missing for two years and began a massive investigation. She is still considered a missing person.

Her father Adam Montgomery said he brought Harmony to be with her mother in Massachusetts around Thanksgiving in 2019, but her mother hadn’t seen her since a video conversation that Easter. Adam Montgomery and her stepmother, Kayla Montgomery, pleaded not guilty on charges related to her wellbeing. They remain in jail. A message seeking comment on the report was left with Adam Montgomery’s lawyer.

Investigators have narrowed the window for her disappearance to 13 days in late 2019, coinciding with the eviction of her father and stepmother and witness accounts of the family living in cars.

Harmony Montgomery was born in Massachusetts in 2014 to unmarried parents who were no longer together and had a history of substance abuse, according to the report by the independent agency. Her father was in prison when she was born.

She is blind in one eye and has behavioral needs, and was in the custody of child protective services in Massachusetts since she was 2 months old. She was moved between the homes of her mother and her foster parents multiple times, the report said, causing “significant trauma and harm.”

Harmony wasn’t made a priority in her own legal case, the report said, with neither the judge nor the attorneys putting her medical, behavioral and educational needs or safety at the forefront of custody discussions. The report also said they did not enforce requirements that govern the placement of children from one state into another.

With the exception of the attorneys for Massachusetts’ child services, all of the other attorneys in the case did not object to Harmony being returned to her father without a home study and didn’t have objections to the fact that he “had never had an overnight visit with her that we are aware of,” Mossaides said. She said the child services’ attorney did not make a strong enough case, though, and was hampered by the inability to effectively assess Montgomery.

Massachusetts’ Department of Children and Families released a statement Wednesday saying it “remains deeply concerned” about Harmony’s disappearance and agrees with the child advocate office that children’s safety should be the “priority not only of DCF but of all the participants in our child protection system.”

“As the OCA report states, the Department continues to make meaningful and lasting reforms,” the statement said.

According to the report, Massachusetts’ child services department had focused primarily on Harmony’s mother, Crystal Sorey. Harmony was removed from her care several times and sent to live with a foster family. The report said that although Adam Montgomery was “non-responsive for long periods of time, during the times when he appeared to be in communication with the DCF case management team, they were not able to engage him, except to facilitate his supervised visits with Harmony.”

Sorey’s lawyer, Rus Rilee, said in a statement Wednesday that despite the admitted failures in the Massachusetts report, the ultimate responsibility for Harmony’s disappearance falls on New Hampshire’s Division for Children, Youth and Families “for failing to remove Harmony from her father’s care and custody after reports that he physically abused her, for which he has been arrested.”