Manitoba

More safe, secure foster placements needed for high-risk teens, inquest finds

Associate Chief Judge Shauna Hewitt-Michta made five recommendations in hopes of preventing similar deaths in the future.

Inquest report released for foster teen who hanged herself in Brandon Correctional Centre in 2013

The girl ended up back in custody on Sept. 20, the day before her 16th birthday. (Getty Images)

She spent her 16th birthday in custody at the Brandon Correctional Centre. No one visited her. A week later she hanged herself.

The teen, only referred to as R.D. in an inquest report released Wednesday, was a permanent ward of Child and Family Services.

She was sexually abused and sexually exploited and as a result was taking medication for PTSD and other mental health conditions.

The inquest heard that neither the teen's case worker from Dakota Ojibway Child and Family Services or staff from her group home, Specialized Foster Homes, contacted Brandon Correctional Centre to tell them about her medication and mental health concerns. 

"Well, she's been in there so many times that I would just assume that you guys [Brandon Correctional Centre] would have a lot of that stuff on file. She's been in there many times," said R.D.'s case worker, Robin Bjornson, during her testimony at the inquest which took place over a span of eight days in 2016 and 2017.

R.D. was a young Indigenous female. She was not murdered and is not missing but she is lost all the same.- Associate Chief Judge Shauna Hewitt-Michta

The teen was considered as being in "complete crisis": running away, abusing drugs and alcohol, and was being sexually exploited by a street gang.

She was moved between 14 foster placements from 2010 to 2012. She was placed with New Directions in a specialized program for sexually exploited teens. The inquest heard she ran away dozens of times and was eventually moved out of the city to a rural foster home, which was privately run by Specialized Foster Homes.

The inquest heard she did well for a number of months, but by summer she was running away again and was arrested on August 30, where she was designated as a high risk for suicide after making a gesture of hanging herself.

The inquest report states she was released back to Specialized Foster Homes and  "on September 9, R.D. made comments related to suicide and was taken to hospital for mental health assessment, cleared, and released."

She ended up back in custody on Sept. 20, the day before her 16th birthday.

It was at that time her CFS worker set up a meeting with her foster home, psychiatrist and RPN, to come up with a better safety plan for R.D. The inquest heard no one from Brandon Correctional Centre was invited because she was set to be released.

The inquest heard everyone was concerned for her safety, in particular the possibility of her running away and getting into a dangerous situation on the streets of Winnipeg. The report said their focus was not on R.D.'s suicide risk.

"RPN Lennon said the primary concern was that R.D. was going to end up missing and murdered," the report said.

Recommendations

Associate Chief Judge Shauna Hewitt-Michta wrote in her report that was not sufficient testimony challenging the child welfare system or information provided on secure foster placements in Manitoba.

"Without more information, it is difficult to make a detailed recommendation but equally tough to ignore the opportunity this inquest offers to draw attention to the need for adequate safe and secure foster placement options for high-risk youth in crisis like R.D.," she wrote. 

She offered a broad recommendation on the issue saying a review must be done on the number of secure foster placements in Manitoba for high-risk youth in crisis. 

Her second recommendation is for all Manitoba child welfare agencies to develop a policy on information-sharing to ensure a child's safety while incarcerated.

The third recommendation builds upon the second saying a policy should be made laying out who's responsibility it is to share that information.

Hewitt-Michta's last two recommendations focuses on corrections: specifically, Brandon Corrections Centre adds more activity options for youths in custody and generally a review of existing training on suicide risk assessment. She noted a review is underway.

"R.D. was a young Indigenous female. She was not murdered and is not missing but she is lost all the same," wrote Hewitt-Michta. "R.D.'s case is another reminder that Indigenous persons are vastly overrepresented in the child welfare and criminal justice systems and in correctional facility populations."