Addressing a meeting on child protection at the Labour Party Conference in Brighton, Allan Bowman said serious case reviews should promote a culture of learning and not seek to apportion blame on individuals.
The improvement agency has proposed a new "systems" model based on the process the aviation industry adopt in the event of a crash or near miss.
Bowman said: "For more than 60 years there have been a succession of inquiries into the children's deaths and some have brought about huge legislative changes.
"Despite these and the hundreds of other reports being made across the country, year after year the same mistakes and same recommendations are being made."
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