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Child-serving System Must Learn From What Happened in Deaths

by NationTalk on April 16, 2008671 Views

For Immediate Release
April 16, 2008

VICTORIA – BC’s child-serving system must act on lessons waiting to be learned from the deaths years ago of four children in Northern BC, and learning from these types of deaths must become more integral to child protection practice, says the Representative for Children and Youth.“A major finding from our investigation is that the Ministry of Children and Family Development and others in child protection must do better at learning from the tragedies of child deaths,” said Mary Ellen Turpel-Lafond. “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.”

In April 2007, the Select Standing Committee on Children and Youth asked the Representative to investigate the lives and deaths of Amanda Simpson, Savannah Hall, Rowen Von Niederhausern and Serena Wiebe. The children died between 1999 and 2005, and each had a family history of involvement with the child welfare system.

“This report is not about fault-finding. By looking back, we more wisely see the path ahead,” said Turpel-Lafond. “Our broad examination of the lives and deaths of these children leads us to specific recommendations — with stated timelines where necessary — that will help improve supervision and training today. Action on these recommendations will support the Ministry’s quick progress in vital areas.”

Examples of problems identified at the time of these children’s deaths which still exist in child protection work today include:

• the need for more complete assessments of child safety, in order to determine if a child needs protection
• necessary improvements in recognizing and responding to complex child abuse and neglect situations
• a continuing lack of information-sharing and coordination between the Ministry and professionals in the community (e.g medical practitioners, police, school officials).

Turpel-Lafond, an independent Officer of the Legislature, said her in-depth investigation also identified areas of Ministry improvement since these children’s deaths, such as staffing levels in the North region.

Currently the North region is staffed at 98 per cent. In early 2000, only 59 per cent of child protection and guardianship positions in the North region were filled, resulting in practice standards not being met.

Throughout the Representative’s investigation and development of the report, specific efforts were made to identify shifts in policy and practice, where the system has been strengthened, and where ongoing challenges remain.
In child death reviews the Representative examines broad issues including but not limited to child protection practice during the child’s life.

Investigations also include looking at communication and coordination by those involved in the child’s life and after the death. This can include police, the medical community, the Aboriginal community, teachers, child care workers, coroners, and the government.

“The investigation into the deaths of Amanda, Savannah, Rowen and Serena identifies potentially life-saving lessons for the child-serving system,” Turpel-Lafond said. “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.”


The full report, “Amanda, Savannah, Rowen and Serena: From Loss to Learning”, is available on the Representative’s website ( ).

Media Contact:
Marg LeGuilloux
Cell: 250.888.8878

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