No improvements in care since deaths of 4 B.C. children: report
System's poor safety standards, bad communication were factors in deaths, watchdog says
British Columbia's child protection system failed on numerous levels when it came to the care of four northern B.C. children who died between 1999 and 2005 while under government supervision, the province's representative for children and youth said in a report released Wednesday.
Mary Ellen Turpel-Lafond examined the roles of the agencies that dealt with the children, including police, government, doctors, coroners, child-care workers, teachers and the aboriginal community.
"Most significantly, the investigation found an inability on the part of the[Ministry for Children and Family Development] to learn from valuable lessons," Turpel-Lafond told reporters at a news conference near the B.C. legislature in Victoria. "Even internal ministry reviews of these deaths provided lessons that were not returned to the frontlines of the system, including … to this day."
"The investigation into the deaths of Amanda, Savannah, Rowen and Serena identifies potentially life-saving lessons for the child-serving system. … We serve their memory best if we use what is learned to support child-protection workers and to support the ministry … to work with them towards growth," she said.
The assessment of the safety of children and planning for them in care had a standard of practice "far below what should be reasonably expected," she said.
"My investigation shows the system failed these children on numerous levels," said Turpel-Lafond.
"Learning from preventable deaths is essential. This investigation found that current safety assessment and planning practices for children have not shown marked improvement since these children died," said her report, entitled From Loss to Learning.
Poor safety standards, lack of thorough medical assessments and insufficient communication between the Ministry for Children and Family Development and professionals in the community played a part in the deaths, the report said.
"An analysis of the evidence provides several possible explanations of why these shortcuts were taken: inexperienced social workers, staff turnover …high caseloads, insufficient supervision, ineffective training and over-reliance on personal intuition when careful fact-finding was required," it said.
3-year-old died in foster care
Three-year-old Savannah Hall was found unresponsive in her foster home in Prince George, B.C., on Jan. 24, 2001. She died in B.C. Children's Hospital two days later.
A coroner's inquest in November 2007 was told that Hall slept in a crib equipped with leather harnesses.
The inquest found Hall's death was a homicide as a result of suffocation. Criminal charges were not laid, but the inquest made 26 recommendations.
Rowen Von Niederhausern, of Terrace, B.C., was 14 months old when he died in August 2002. A coroner's jury found he died of brain injuries as a result of accidental shaking.
Serena Leona Marie Wiebe died in Fort St. James in June 2005. She was just seven months old.
Last June, a coroner's jury concluded the 1999 death of four-year-old Amanda Simpson of Prince George was a homicide caused by non-accidental head trauma. Simpson died Nov. 2, 1999, three days after suffering extensive head and bodily injuries while at home in the care of her stepfather.
The report cites the Simpson case as an example of poor communication.
"Despite multiple reports of abuse and neglect between 1997 and 1999, the ministry did not report any of these to the police," the report says.
"Community professionals reported that one of the children was being sexually abused and had other suspicious injuries; additional reports of suspected physical abuse were made to the ministry on two occasions in October of 1999."
The jury in the Simpson case called on the B.C. Ministry of Children and Family Development to take steps to improve its ability to protect children, upgrade training for social workers and spend more on child protection resources.
Minister defends improvements in care
Minister of Children and Family Development Tom Christensen said several of the proposed changes are already underway, including hiring more staff in northern B.C.
"We've gone from a position of about 58 or 59 per cent of our staffing positions being filled in 1999 to 98 per cent today," he told CBC News after the release of the report. "That's critical because you actually have to have people in social work positions if you're going to do important work with children and families."
But NDP Leader Carole James said the system isn’t improving fast enough.
"We've lost seven years. Seven years where children have had less services because of Gordon Campbell and the Liberals' direction," she said. "Seven years where they took apart services and supports. And even when they were reminded by Ted Hughes just a few years ago, services still hadn't improved."
In 2002, a year after it took power, the Liberal government cut the office of the children's commissioner, citing a review that found too much duplication between that office, the B.C. Coroner's Service, the child and youth advocate and the ombudsman.
New report echoes past recommendations
In April 2006, retired Judge Ted Hughes released a 172-page report into B.C.'s child protection system in which he blamed budget cuts and internal upheaval for many of the problems.
Hughes recommended the appointment of an independent officer of the legislature to oversee the child protection system, review children's deaths and advocate for improved services. That recommendation lead to the creation of Turpel-Lafond’s position.
Hughes, B.C.'s former conflict-of interest commissioner, was appointed to investigate the system in 2005, as controversy intensified over the government's handling of the case of 19-month-old Sherry Charlie.
The toddler was beaten to death by her uncle in Port Alberni, B.C., in 2002 after a government-approved First Nations child welfare agency placed the girl in his home. Ryan George, 32, was later sentenced to 10 years for manslaughter in the case.
Judge Thomas Gove headed an inquiry into child protection in B.C. in 1995 and recommended 118 changes to the system. When in 2000, he spoke about whether there had been improvements made in the child protection system in the five years since his report, his words were similar to Lafond-Turpel's today.
"It's evident some of the structural changes that were necessary to provide proper services to protect children and help their families simply have not been implemented, or have not been implemented in an effective way," Gove said at the time.