(Associated Press/John Minchillo)
New York City Department of Investigation Commissioner Mark Peters listens during a round table conference with reporters at the Manhattan District Attorney's offices, Wednesday, July 2, 2014, in New York.

Two New York City children died as a result of neglect and abuse because the city's Administration for Child Services (ACS) demonstrated "systemic" failures in protecting their well-being, a Department of Investigation report has determined.

The report released Tuesday outlined alleged missteps and systemic deficiencies at the child-welfare agency — including failure to follow basic procedure, identify signs of neglect, repeated abuse, and starvation.

"On several occasions ACS and its provider agencies failed to take necessary steps to protect children and at times may actually have put them in harm's way," the department's commissioner Mark Peters said in a statement.

"Equally troubling, data obtained by the DOI suggests that these are not isolated instances and that ACS may have repeatedly failed to meet legal and procedural requirements," he said.

The 18-month investigation focused on three children, who were identified only by the pseudonyms "Chris," "Morgan," and "Alex" for the sake of confidentiality.

The report concludes that in each of the three children's cases, the child-welfare agency had "multiple opportunities" to intervene in what were considered dire circumstances, but didn't.

(Dan Kitwood/Getty Images)

Severely malnourished, with life-threatening injuries

"Chris" nearly died from an injury inflicted by one of his parents, despite four previous ACS investigations of his case that were performed over the course of two years.

Those investigations revealed increasingly severe physical injuries. The report found that ACS failed to follow its investigative procedures during that period, and didn't interview his friends, who allegedly knew he was being abused and starved at home.

The report says caseworkers assigned to Chris also grossly overestimated his weight, and didn't verify with a doctor whether his injuries were caused by accident, as his parents had claimed. The report found that the caseworkers didn't take proper investigative steps until Chris suffered a life-threatening injury — after which he was placed in foster care and his parents arrested.

Chris is now living with a relative, and his siblings are in foster care while their parents' criminal cases are pending.

(Mario Tama/Getty Images)

Cocaine and death under "suspicious circumstances"

"Morgan" died "under suspicious circumstances" related to neglect, the report found. Morgan's cause-of-death could not be determined, but the report found that ACS had documented 11 instances of neglect on the part of Morgan's mother involving her other children over the course of 12 years.