The watchdog also said long delays in producing the review findings "severely restricted" the potential to learn from the reviews.
Ofsted's chief inspector of schools, Christine Gilbert, said: "Everyone involved in child protection in any way must take stock of the role they play, and consider how, be it as frontline staff, policy makers, or regulators and inspectors, they can and must improve the system."
She added: "We are still not learning enough, or fast enough, from serious case reviews which happen when a child has died or been harmed through neglect or abuse."
The findings are part of Ofsted's annual report into the state of England's education and children's services.
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