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From Loss to Learning: Executive Summary and Introduction
Amanda, Savannah, Rowen and Serena:
From Loss to Learning
April 16, 2008
The Honourable Bill Barisoff
Speaker of the Legislative Assembly
Suite 207, Parliament Buildings
Victoria BC V8V 1X4
Dear Mr. Speaker,
I have the honour of submitting Amanda, Savannah, Rowen and Serena: From Loss to Learning to the Legislative Assembly of British Columbia.
This report is prepared in accordance with Section 16 of the Representative for Children and Youth Act, which makes the Representative responsible for reporting on reviews and investigations of deaths and critical injuries of children receiving reviewable services. In this instance, the report deals with the April 26, 2007 referral made by the Select Standing Committee on Children and Youth.
Mary Ellen Turpel-Lafond
Representative for Children and Youth
pc: Mr. Ron Cantelon, MLA
Chair, Select Standing Committee on Children and Youth
Mr. E. George MacMinn, QC
Clerk of the Legislative AssemblyExecutive Summary
In April 2007, the Select Standing Committee on Children and Youth asked the Representative to investigate the deaths of four Northern B.C. children who died between 1999 and 2005. Amanda Simpson, Savannah Hall, Rowen Von Niederhausern, and Serena Wiebe were all between the ages of seven months and four years at the time of their deaths. Each had a family history of involvement with the child welfare system.
Their names are used in full in this report because all were the subject of coroner inquests in 2007. However, their names also form the title of this report to focus us all on the heart of this investigation – four young B.C. lives whose voices are no longer heard.
The death of a child affects everyone, whether as a personal loss or a collective sadness. As individuals or as a concerned community, we not only ponder how and why a child died, we also ask if there is anything that could have been done to prevent it.
That essential question drives this child death investigation. By looking closely at the lives and deaths of a number of children, the Representative’s report moves from a detailed look at individual cases towards overall analysis of system of supports, whether significant improvements have been made in the years following their deaths, and eventually to what remains to be improved. It serves a crucial public accountability function.
The Representative’s role is not one of fault-finding. In this report there are occurrences where it is clear that errors or misjudgements by individual service providers or their supervisors are a crucial part of the unfolding story. There is no easy way around this, nor should there be. However, where this arises, the greater good can be served by also assessing broader issues of supervision, quality assurance and operation of the child protection system.
The work of the men and women on the stressful front lines of the child protection system must always be honoured. When a child dies who has been involved with the system, people at all levels of the system experience a deep emotional impact and sense of loss. We owe them all a genuine commitment to acknowledge the challenges and complexities confronting families and professionals, while at the same time ensuring death reviews are allowed to be a respectful opportunity for learning. The surviving siblings, parents and extended families require our compassion and support. Ensuring that the death of their loved ones not be invisible may be one of our most effective expressions of that compassion.
…the primary purpose for reviewing injuries and deaths of children and youth who are in care or receiving Ministry services is to point the way to continuous improvements in policy and practice, so that future injuries or deaths can be prevented…
A secondary purpose…is one of public accountability…the government has a responsibility to account to the public as to whether it has met its responsibilities to that child. The purpose is not to assign blame to individuals but to learn from mistakes and understand what went wrong and what went right.
– Honourable Ted Hughes, QC, BC Children and Youth Review
The Representative’s investigation has determined that the system failed these Northern B.C. children on numerous levels. This knowledge must drive us to seek out the enduring lessons for today’s practitioners. The silencing of these children’s voices must stir us to move from loss to learning.
This report is the first external, independent and completely comprehensive investigation relating both to the services these children and their families received, and the circumstances relating to their deaths.
Although these deaths occurred before the creation of her new independent office, the Representative determined – and the Select Standing Committee agreed – that these particular deaths raised questions around systemic issues that warranted further investigation.
Given the time span of the involvement in the child–serving system of the children and their families (in excess of a decade), the Representative’s office conducted extensive evaluation of the practice and policies during the entire period. Specific efforts were made to identify shifts in policy and practice, where the system has improved and strengthened, and where ongoing challenges remain.
The Representative’s process examines broad issues, for example (but not limited to) child protection practice issues during the child’s life, and communications between parties involved in the child’s life and after the death. These can include police, the medical community, the Aboriginal community, teachers, child care workers, coroners, and the government.
The first stage of this investigation involved a review of all records for each of the four children and their families. Materials and transcripts from the coroner’s inquests were analyzed, and Ministry staff interviewed. Experts on the Representative’s Multidisciplinary Team then analyzed data and provided valuable advice for the Representative with respect to recommendations. The investigation also involved looking at the patterns, trends and risk factors which may have contributed to the deaths. Themes identified by the review of material, interviews and investigation, as well as those highlighted by the Multidisciplinary Team, were explored.
In addition, the Representative met with family members who wanted to discuss the death of their relative. Siblings, parents and other relatives of these children maintain a profound and personal interest in seeing improvements to B.C.’s child serving system. The Representative is deeply honoured by the trust some family members have placed in her, by their honesty and willingness to share their pain.
Issues identified in the lives and deaths of these four children that present challenges in current child and youth practice include:
• assessments of the children’s safety falling below accepted standards
• significant guardianship practice deficiencies
• lack of thorough medical assessments for vulnerable children
• weaknesses in clinical supervision and case consultation
• lack of cultural planning for Aboriginal children in care, and cultural context in assessing safety
• insufficient communication between the Ministry and professionals in the community
• human resource challenges impacting the ability to provide safe and effective child welfare services
• uneven quality assurance practices not sufficiently focused on outcomes/results for children.
Examining these four deaths does not provide information to make sweeping conclusions on the child welfare system. It does identify systemic failings and cracks these children and their families fell through at the time, which leads us to examine progress to the current situation.
The detailed analysis that follows in this report focuses on identifying those enduring lessons that can be used to inform improvements to the child serving system and child protection.
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