Deaths of children puts child welfare system in hot seat

They are the heart of an investigation, but their voices will never again be heard. That is how Mary Ellen Turpel-Lafond framed the introduction of the report into the deaths of four northern British Columbia children, all with a history of involvement with the child welfare system in the province.
The question at the centre of the report done by British Columbia's office of the independent Representative for Children and Youth is: Was there anything that could have been done to prevent the deaths of Amanda, Savannah, Rowen and Serena. They were tragically lost to us between 1999 and 2005. Of the four children, three were Aboriginal.
"Their unique circumstances and the vulnerability of Aboriginal children, particularly in northern British Columbia, will be a necessary focus in improving the system," the report reads.
The report focuses on an overall analysis of a system of supports available at the time of their deaths, whether significant improvements have been made in the years following, and what remains to be improved.
What Turpel-Lafond's investigation reveals is that the system failed each of these children "on numerous levels." Of the issues identified, the report concluded there was a lack of cultural planning for Aboriginal children in care, and cultural context in assessing safety; there was insufficient communications between the ministry and professionals in the community; and there were human resource challenges impacting the ability to provide safe and effective child welfare services.
The children's whose deaths motivated the report lived in the Ministry of Child and Family Development's North region, an area that encompasses 925,000 sq km. As stated in the 2006 census, there are 289,000-plus people in the area, accounting for 6.7 per cent of the province's total population.
There are challenges associated with delivering services in a number of small isolated towns, villages and First Nations communities, over a wide expanse of land, acknowledges the report, including staffing issues, and the time eaten up by travel getting from one population centre to another.
"In the case of First Nations communities, there can also be jurisdictional issues between the federal and provincial governments."
There are 51 First Nations in the region, and 16.6 per cent of the total population is Aboriginal in the North region, as compared with 4.5 per cent of the provincial total population.
Amanda Simpson was Métis and died of head and internal injuries. She was four years old.
Savannah Hall was a First Nations child in the ministry's care from the age of eight months. She died as a result of brain damage cause by lack of oxygen to her brain. She was three years old.
Rowen Von Niederhausern died as a result of swelling to the brain at the age of 14 months.
Serena Wiebe (John) was First Nations and died in her sleep at the age of seven months old. A coroner's inquest classified her death as undetermined.
The stories of the short lives of the four children at the centre of the report are heart-breaking, though told without sensation by the representative. Each paragraph of the tale demonstrates the breakdown of family and parental responsibility and of the systemic failure of the safety net designed to protect the vulnerable.
The themes that emerge from the investigation run like threads through the stories, weaving a ragged tapestry: assessments of the children's safety were non-existent or incomplete, medical assessments were neither timely nor thorough, supervision was not effective and staffing levels inadequate.
It was also important, the independent representative concluded, that measures be taken to preserve Aboriginal identity. For instance, the Aboriginal identity in the case of Amanda was not known until after her death, and that information played no part in informing her care.
Amanda's family had come to the attention of the ministry on a number of occasions over many years and during two distinct periods of time. The first between 1991 and 1994.
When Amanda was two years old in 1997, the ministry again began to look at the family when it was reported that a six year old sister was often the only one to care for her younger siblings, ages one, two and four years old. She fed them freezies and ice cream to keep them quiet. One time the children started a fire to stay warm. The fire department attended the scene.
It was the six-year-old child that requested help for her family.
Over the years, ministry staff had many opportunities to assess the safety of the children and family interaction. The family faced domestic violence, poverty, and drug and alcohol abuse. Between September 1997 and February 1998, the family had four different child protection workers.
The first began an investigation, but passed it on to the second for completion but the intake was not registered in the new electronic case management system. After a home visit that did not address "the significant child protection issues disclosed by the child, the second worker was unable to follow up with the family because of workload issues," the report states.
The worker left the employ of the ministry and the investigation was not completed. One year later, a third worker was assigned to the family when a caller reported Amanda's mother smoking "a lot of pot," and yelling at the children. There were allegations of not enough food in the house and that the RCMP was involved after the mother assaulted a neighbor.
Just 18 months after the first worker handed off Amanda's family file to the second, a fourth worker was handed the file about the investigation the third worker had opened.
Amanda's drama, described with compassion and sensitivity in the representative's report, continued to unfold until Nov. 2, 1999 when she succumbed to "massive head and abdominal injuries" suffered on Oct. 29, 1999.
"The autopsy concluded that Amanda's injuries were not accidental, but consistent with inflicted trauma."
The report outlines the children's stories in detail, and evaluates the steps, or mis-steps, the ministry made in attempts to protect them.
With the advantage of hindsight, the report speaks to inadequacies in that protection, including "failing to gather and assess all of the family history, incomplete interviews with the children and the parents, and incomplete information from key members of the community. These inadequacies resulted in a failure to assess the children's safety and intervene in a timely manner."
But perhaps the worst condemnation was Turpel-Lafond's assessment that the standard of practice of those years had not "appreciably improved during the entire time, until today."
As a resultof her investigation,Turpel-Lafond made 11 recommendations to improve service for today's vulnerable children. Some deal with improved training of front-line workers, others with the recruitment and retention of workers, and others on risk assessment and reporting, including key measures for Aboriginal children in care or receiving services by the North region. The full report and recommendations can be reviewed on the Web site of the Office of the Representative For Children and Youth at www.rcybc.ca.
The Union of BC Indian Chiefs was quick to call on the Ministry of Children and Family Development to fully implement the recommendations.
"We cannot afford to continue to look the other way as our communities are in crisis," said UBCIC President, Grand Chief Stewart Phillip. "With the barrage of youth suicide rates, combined with drug-and gang-related violence, it is more important than ever that we continue our focus on our children. We cannot afford to stand by silently as the child apprehensions occurring in our communities reach epidemic proportions."
Provincial NDP Leader Carole James called the report a "stinging indictment of seven years of failure, neglect and inaction by the [Gordon] Campbell government in the field of child protection."
She went on to note that there had not been an improvement in child protection services since 2001 when the government promised "transformative change." The Campbell Liberals, therefore, had not made the improvements necessary to meet the needs of children at risk in B.C., James said.
In releasing the report, Turpel-Lafond said the child-serving system must now act on "lessons waiting to be learned from the deaths years ago of four children."
"A major finding from our investigation is that the Ministry of Children and Family Development and others in child protections must do better at learning from the tragedies of child deaths. And a better job also has to be done in getting lessons quickly and effectively back to front-line workers. These people protecting our children must be supported in improving the social work practice that can so often change lives."
Problems she identified that still exist today include: the need for more complete assessments of child safety, in order to determine if a child needs protections; necessary improvements in recognizing and responding to complex child abuse and neglect situations; a continued lack of information-sharing and coordination between the ministry and professionals in the community, including medical practitioners, police, and school officials etc.
"The investigation into the deaths of Amanda, Savannah, Rowen and Serena identifies potentially life-saving lessons for the child-serving system," said Turpel-Lafond. "The legacy of these children must be that we learn from those lessons and move forward. The legacy of their short lives and silenced voices must be a better system."