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A System Broken and 21 Babies Dead

The shocking diagnosis and prescribed fixes from BC's independent children's watchdog.

By Tom Sandborn, 28 Jan 2011, TheTyee.ca

Mary Ellen Turpel-Lafond, BC's representative for children and youth

Mary Ellen Turpel-Lafond, BC's representative for children and youth.

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Twenty-one babies died in their sleep, and not enough was done to protect them. That is the grim message of a report issued yesterday by Mary Ellen Turpel-Lafond, B.C.'s representative for children and youth. The report looks into the deaths of 21 children under two years of age between 2007 and 2009.

The report, "Fragile Lives, Fragmented Systems: Strengthening Supports for Vulnerable Infants", calls on the government to develop provincially coordinated standards for postnatal public health nursing in the province. Ms. Turpel-Lafond is the province's first representative for children and youth, appointed in 2006 after the passage of a bill creating the post.

In addition to highlighting the role of poverty and intergenerational trauma in the families of the children who died, the report calls for a much more integrated and coordinated approach to child welfare in the province.

The report emphasizes the need for better reporting and review by ministry staff of critical incidents in which children in care are hurt or killed.

"What this report reveals is a system in disarray," Linda Korbin, president of the B.C. Association of Social Workers, told The Tyee by phone on Jan. 27. "The government has simply failed to provide enough resources and staffing to do the job."

Adrienne Montani, of the advocacy group First Call agrees with Korbin.

"One of the two key themes of this important report," Montani told The Tyee, "is how deeply poverty hurts children, and how deep the impact is on aboriginal children of intergenerational colonization and poverty. When you add that to an inadequately staffed and stressed out ministry with overworked social workers, you are setting people up for failure."

"The second important lesson is that the system is fragmented and flawed, underfunded and underresourced," she said. "There has been far too much churning of structure in MCFD, and the ministry has lost far too many workers. This means the ministry's many hardworking and professional staff don't have the resources to do the essential preventative work that would have helped protect these children."

'Some very likely' would have lived: Turpel-Lafond

"It isn't possible to say that with adequate services, all of these infants would be alive today, but as birth circumstances and multiple common risks play such significant roles in healthy infant development, it is reasonable to say that some of them very likely would be," said Turpel-Lafond. "The lack of rigorous, integrated system-wide services and interventions led to many missed opportunities for prevention and effective response."

All the deceased children were known to the ministry of children and family development, and they all died in their sleep. Fifteen of the children were from first nations families, and nine of those 15 died on Vancouver Island. (The infant mortality rate for first nations children in B.C. is twice the rate for non-Aboriginal children.)

The children who died under MCFD attention came from families that had already experienced significant trauma, the report notes. Twenty of the 21 families had suffered intergenerational trauma, with 15 of the mothers' families having documented abuse or neglect, and 14 having incidents of domestic violence reported. Sixteen of the families had reported issues with substance abuse, and 12 had reported instances of depression or suicidal behavior. Despite all these warning signals, the report notes:

"Some of the most fragile families in our province are slipping through huge cracks here. Government needs to take a hard look at this. We need to fix the existing lack of a coordinated and responsive approach, and create seamless coordination among all support services."

The report notes that only 14 of the 21 deaths were reviewed by the ministry, and calls for improvements in MCFD internal review practices. But Darren Harbord, a media spokesman for the ministry told The Tyee yesterday that all 21 cases had gone through a preliminary review process. In seven of the cases, he said, there was no direct link between ministry practices and the incidents that occurred. For instance, there were situations in some of them where the infant was medically fragile or died of natural causes.*

Lines of responsibility blurry

The representative's report, however, suggests that the 14 death reviews that were conducted shared some disquieting shortfalls, including lack of clarity on how the decision to review was made, inadequate terms of reference, analysis that missed key issues, recommendations that failed to address issues revealed in earlier analysis, lack of information as to whether any action had been taken on recommendations and failure to meet ministry standards in terms of time lines for completing reviews.

The MCFD's Harbord told The Tyee that six children died in ministry care in the first half of 2010, the most recent figures available. Three deaths, he said, are classified as "natural"; one is classified as "accidental" and two are currently classified as "undetermined" and still being investigated by the Coroner's Office. However, if the scope of the question is widened to include children receiving ministry services as well as those in care, government figures show the number of fatalities for the first half of 2010 goes up to 29.

In a report issued last December, Turpel-Lafond indicates that her office and MCFD staff sometimes disagree about whether a critical incident report ought to be filed. Addressing a situation in which a vulnerable special needs child was left unattended with her mother's body for several days after the mother's death, the report notes:

"In relation to the case of the child with the deceased mother, following a review of the file and of relevant information from within and outside the ministry, the representative has determined that a critical injury has in fact occurred. The representative has completed a review under the Representative for Children and Youth Act (RCYA), and has commenced a full investigation of this matter. However, the representative has to date still not received an official ministry report of the critical injury in this case. Discussions with senior ministry officials suggest a notification will not be forthcoming."

This continued unwillingness to provide the representative with a notification regarding this death is despite the clear requirements of the Representative for Children and Youth Act, Turpel-Lafond argues in her December report. She stresses that leadership figures in the ministry need to encourage full reporting of all critical incidents that lead to injury or death, writing that "it is the representative's view that it is not appropriate for ministry leadership to encourage or tacitly endorse a narrow view of the RCYA that limits the duty to notify the representative of a critical injury to a child."

Another tally of harmed children

Another perspective on how well children are doing while in the care of the ministry of children and family development is found in a recent report from the public guardian and trustee of B.C.

Looking at critical incidents reported by the ministry to the office of the guardian and trustee during the same time frame as the Turpel-Lafond report, 2007-2009, the guardian's report says that 624 critical incidents occured involving children in the "continuing care" of the ministry.

These incidents involved 463 children, with 105 children involved in two or more critical incidents during the report period. Most of the critical incident reports involved older kids, with 409 being filed for children between 15 and 18. Three hundred and seventy five of the incidents involved injury or harm, and of those, 235 reported someone who caused the harm.

Of those who were reported as harming children in care, 55 were foster parents or unrelated caregivers, 54 were friends or acquaintances, and 18 were parents or other relatives.

The office of the public guardian and trustee is responsible for defending the financial and legal interests of its wards, as co-guardian together with the ministry, of all children whose parents are unable to care for them. The split guardianship structure (with the ministry as guardian of persons and the office of the guardian as protector of the child's legal and financial interests) is desirable, the report argues, so that the public guardian and trustee can criticize the ministry, and, if necessary, sue the province for negligence.

Contacted yesterday, Stuart Chase, media spokesman for the public guardian and trustee, was unable to tell The Tyee whether his organization had in fact ever exercised the negligence suit option.

*Story updated at 10:30 a.m., Jan. 28, 2011. [Tyee]

Contributing editor Tom Sandborn covers labour and health policy beats for The Tyee. He welcomes story tips and feedback at tos@infinet.net.

17 Comments:

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  • Fiat lux

    1 year ago

    I wonder when she'll get

    I wonder when she'll get fired, questioning our great, wealth creating economic system ?

    After all, those CEOs and senior executives deserve their multimillion salaries, because they "earn" it, by cutting wages and increasing prices to the public, the logical way of wealth creation.

    And like one of our former PC MPs wrote in out local papers, years ago: "Children in Africa are starving, because their parents aren't productive"

    Now, if the parents of those Canadian children had been "productive", the kids wouldn't have died.

    Just ask the Fraser Inst.......

    Ed Deak.

  • Van Isle

    1 year ago

    Maybe one of Gordo's last

    Maybe one of Gordo's last acts is to fire Ms. Turpel-Lafond so his successor doesn't have to deal with those nasty, bothersome and NDP-friendly reports.

  • Wendy Bradley

    1 year ago

    Thank you!

    Thank you, Mary Ellen Turpel-Lafond. You likely have an extremely hard, thankless job, so I'd like to change that for a second. And thank you too, Tom Sandborn. Who knows – maybe a candidate for office will get wind of this piece , and decide to stand tall with leadership, advocacy, and money to help fix a gutted system for our kids living in poverty. Seriously – many thanks – Never give up.

  • cboo44

    1 year ago

    Not enough resources?

    WHAT ?? The TAXPAYER provides 14 BILLION DOLLARS A YEAR to aboriginal support across Canada. 14 BILLION ! Am I mistaken in thinking that in between all the siphoning off of dollars for every bureaucratic "procedure" and $300 a day for every chief and councilor of EVERY band, and a QUARTER OF A MILLION A YEAR for every chief, JUST MAYBE somebody could find a few "resources" for native kids?
    Isn't it time that people who are RESPONSIBLE for the delivery of services to native people got their noses out of the trough long enough to actually do something productive with all that cash?
    How about stop the tax dollar sucking from every level of government and get to work providing proper support for natives?

  • Fiat lux

    1 year ago

    Look at the executive

    Look at the executive salaries in corporations and then guess where the chiefs have learned it ?

    Ed Deak.

  • mary jane

    1 year ago

    greed leaves is mark

    The poverty in BC is so severe that we have these types of articles. Greedy politians, friends and their friends might be greedy landlords. This morning the whole world seems tired of being mde responsible to assure others get rich. All the while home;essness grows and kids kids and their parents suffer hunger and other poverty related problems.

  • mary jane

    1 year ago

    Agreed

    I agreed this is a time to say Thank You for writing these articles And a big Thaks to Mary Ellen Turpel-Lafond, for coming forward to alert us to how bad our province really. The world is starting to complain loudly

  • the bon

    1 year ago

    The Province Newspaper

    You can see how much attention the Province newspaper gives this story, it's relegated to the last couple of pages of the news part (just before the sports section!!!) If anyone doesn't think BC media is is a BC Liberal propoganda machine........

  • morechatter

    1 year ago

    Christie Clark was also Minister of Children

    Before she resigned and there was controversay over a young child dying needlessly while Clark was Minister. [UNSUBSTANTIATED CLAIM REMOVED. -MODERATOR.]

  • Fii

    1 year ago

    Is some of this money going

    Is some of this money going towards better education for Aboriginal teen girls and boys-EARLY?? Like at age 13 and 14. Do these young women have free and easy access to birth control?? Are they raised to believe they have the power to stop the recurring cycle of abuse and (I'm guessing) teenage pregnancy?

    "15 of the mothers' families having documented abuse or neglect, and 14 having incidents of domestic violence reported. Sixteen of the families had reported issues with substance abuse, and 12 had reported instances of depression or suicidal behavior". WHY??????

    Throwing money and resources at the problem indefinitely isn't the answer. Prevent it.

  • mary jane

    1 year ago

    Money buys

    Saw the tv version
    Money buys
    1.food for better basic health
    2. proper baby equipment
    3. better housing
    4. cleaning solutions such as bleech
    5. stuff to kill mold
    6 Paint to help kill the mold
    7 a government that cares and doesn't think allowing anyone to go without the basics

  • lynn

    1 year ago

    Thank you, Mary Ellen Lafond - Turpel

    Quote:

    "The office of the public guardian and trustee is responsible for defending the financial and legal interests of its wards, as co-guardian together with the ministry, of all children whose parents are unable to care for them. The split guardianship structure (with the ministry as guardian of persons and the office of the guardian as protector of the child's legal and financial interests) is desirable, the report argues, so that the public guardian and trustee can criticize the ministry, and, if necessary, sue the province for negligence.

    Contacted yesterday, Stuart Chase, media spokesman for the public guardian and trustee, was unable to tell The Tyee whether his organization had in fact ever exercised the negligence suit option." End of quote.

    Would this be the same Stuart Chase, that was a junior Public Affairs Bureau employee who sat in BC Supreme Court taking notes that were being reported back to the Attorney-General's ministry?

    About which Bill Tieleman had this to say:

    Quote:

    "Then-Attorney-General Wally Oppal wrongly told the BC Legislature that Chase was in court to "assist the media" with the case "that's all he's there for" - when in fact, Chase had not spoken to any media covering the hearings until I approached him to find out who he was.

    A subsequent Freedom Of Information request I filed and received in 2007, and an appeal to get several withheld portions of Chase's notes, showed that Chase was in fact politically monitoring the case, including reporting on who was in attendance.

    In court Tuesday, defence lawyer Kevin McCullough raised the Chase monitoring and said he wants to know who the reports went to within the government." End of quote.

    Is this the same Stuart Chase who was 'politically monitoring' FOR government then?

    Why, then, would we ever have any confidence in him that now as 'media spokesman' for the public guardian and trustee ( protector of children...with the right to criticize the ministry and sue the province for negligence), why then, would we ever have any confidence that he wouldn't be 'protecting' government once again?

    His appointment to this job, (tragically) explains a lot.

    Is the government being protected, rather than children?

  • Fiat lux

    1 year ago

    As, so called "political

    As, so called "political economist", Professor Emeritus John Crispo of Toronto U, said it during the FST debates in 1988: "It makes no difference who owns the country, as long investment is permitted to move freely".

    And this is the crap they're teaching in our universities now, and how and why fascist "conservative" politicians see to it that everything and everybody is stolen blind, legally, to fulfill the demands and promises of the presently ruling, sick, economic theory, the biggest crime wave in human history.

    Ed Deak.

  • Grania

    1 year ago

    Why Kids Die in BC

    The provincial government started decimating MCFD at the beginning of their power. Over the years they have been in power; resources have been slashed and accountability has vanished unless the media gets involved. This government does not want children to really be protected. That might cost money better used on plastic decor or the Olympics. However, this government does want social workers to APPEAR to be protecting children. God help the social worker, with no tools, who cannot put up a good appearance or who might say something critical to the public. What is now required is for someone to convince Ross Dawson to return and replace duToit who is an embarrassment at best and who has not achieved even one stated goal since her arrival. Upper management needs to be gutted. These people are over paid, get CEO type bonus payments for things like throwing folks off of welfare, and these people do nothing and in fact never even SEE a client! They push paper and have meaningless meetings and do lunch together. Get rid of them. Line workers just delete the management by email that they perpetrate anyhow. The money that would be reclaimed would reinstate important resources to this Ministry.

  • Fiat lux

    1 year ago

    What people will have to

    What people will have to realize one day, that the culprits are not governments, or politicians in general, because all they're doing is instituting and enforcing criminal theories originating from priesthoods.

    Today's so called "economists" are, in reality, the Priesthood of the Money God, and , as priesthoods of history have always been doing, interpreting and passing on the orders of imaginary deities, licencing to steal, destroy and kill by "divine orders".

    We can protest and change governments as much as we imagine, it won't make any difference, as long as the " Priesthood of economists" declare that to "remain competitive", governments must search, steal and destroy.

    As long as "competitiveness" is the magic password to "wealth creation", we'll get more poverty, more environmental destruction and more kiddies starving and dying.

    After all, children are not "competitive" so who gives a damn if they die, according to the warped theories of warped minds.

    Ed Deak.

  • Fiat lux

    1 year ago

    Does anybody ever wonder how

    Does anybody ever wonder how is it that with bank deregulation there's all kinds of imaginary capital available to take over and control resources and economic systems by the global corporate mafia, but always lesser and lesser funds for social services and to save lives ?

    Ed Deak.

  • realisticman

    1 year ago

    Ed

    The banks in Canda ARE regulated.

    "Canada's federal government has sole jurisdiction for banks according to the Canadian Constitution, specifically Section 91(15) of The Constitution Act, 1867 (30 & 31 Victoria, c.3 (UK)), formerly known as the British North America Act, 1867. Meanwhile, credit unions/caisses populaires, securities dealers and mutual funds are largely regulated by provincial governments.

    The main federal statute for the incorporation and regulation of banks, or chartered banks, is the Bank Act (S.C. 1991, c.46), where Schedules I, II and III of this Act list all banks permitted to operate in Canada under these three distinct categories:

    * Schedule I: Banks allowed to accept deposits and which are NOT subsidiaries of a foreign bank. Examples include "The Big Five" banks (as mentioned above) and smaller second tier banks such as National Bank of Canada, Laurentian Bank of Canada and Canadian Western Bank. Because the Schedule I banks are not subsidiaries of any foreign bank, they are the true domestic banks and are the only banks allowed to receive, hold and enforce a special security interest described and provided for under the Bank Act and known to Canadian lawyers and bankers as the "Bank Act security".

    * Schedule II: Banks allowed to accept deposits and which are subsidiaries of a foreign bank. Examples include P.C Financial, AMEX Bank of Canada, Citibank Canada, HSBC Bank Canada, ING Bank of Canada and Walmart Canada Bank. Like the Schedule I banks, the Schedule II banks are incorporated under the Bank Act.

    * Schedule III: Foreign banks permitted to carry on business in Canada. Examples include Bank of America, Capital One, Credit Suisse and Deutsche Bank AG. Unlike the Schedule I and Schedule II banks, the Schedule III banks are NOT incorporated under the Bank Act and they operate in Canada, usually within the country's largest cities (being Toronto, Montreal and Vancouver), under certain restrictions mentioned in the Act.

    The bank regulator is the Office of the Superintendent of Financial Institutions (best known as OSFI), whose authority stems from the Bank Act. The financial groups are also governed by regulatory bodies (bank regulators, securities regulators, insurance regulators, etc.) in each country they operate in."

    Wikipedia

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