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Cody's Death: How Deep an Investigation?

The Fontaine toddler died in a troubled home after social worker cutbacks. But the Liberals killed the Children's Commission -- and its power to investigate government fault. A TYEE SPECIAL REPORT

Judith Ince 11 Jan 2005TheTyee.ca
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Cody Fontaine's brutal life ended two weeks ago in the jaws of the family dogs, while his mother, her boyfriend, and another adult slept.  His siblings found his lifeless body just before noon, and have now been removed from the care of their mother.

Media attention has largely focused on the dogs' role in the tragedy; there have been calls for restrictions on potentially aggressive dogs like Rottweilers, which were part of the family's menagerie. "When a young boy dies needlessly, we need to make certain that his death is not in vain," opined the Vancouver Sun. "The dogs that killed Cody were quite simply, instruments of deadly force." It's time to strengthen the dog laws, the editorial concluded.

Sherri Fontaine, Cody's mother, took second place to the snarling dogs in the press.  A woman with a long history of legal and drug problems, Fontaine was rebuked by an editorial in the Maple Ridge Times."You may think it's harsh, but drug dealers don't deserve care [sic] for kids, no matter how much they might be grieving."  

But beyond dangerous dogs and mothers with a dodgy past, important questions remain.  Have cuts to the Ministry of Children and Family Development (MCFD) affected levels of support given to a family with multiple challenges? Did the social workers involved with the family have sufficient resources to adequately investigate the level of risk faced by Cody Fontaine and his siblings? And who will ask these questions—and demand answers to them?

Falling responses to complaints

John Irwin, of the Canadian Centre for Policy Alternatives has examined the effects of MCFD budget cuts to staffing levels. Using data from the ministry, he found that the numbers of social workers has declined somewhat, from 2206 in 2002 to 2144 last year, a decline of only 3 percent.  However, support staff—secretaries, administrators, clerks—have taken a dramatic hit, falling from a high of 5,076 in 2001 to 3983 last year, a drop of over 20 percent.

In addition, there has been a significant fall in the number of ministry investigations of reports of potential child neglect or abuse. The ratio of responses to complaints in 1999 stood at 73.2 percent, but by last year it had fallen to 58.7 percent. "If you look at the drop in FTEs [support staff] and the number of investigations, they seem to follow one another," he says. 

Shelley Linton is the principal of Riverside school in Maple Ridge, where Cody Fontaine's siblings were students.  She says the community served by the school has many vulnerable families, as well as a high number of "low-incidence" students—that is, children with significant emotional, physical or intellectual challenges. "I find that social workers are very overworked and have a lot on their plate," she says. "I think there is a squeeze on. Before, help came faster and lasted longer."

Paul Jenkinson, the chair of the BC Association of Social Workers' child welfare committee, confirms Linton's observations. "Look at how much was cut from the budget, and how much was spent on devolution to community governance," a total he reckons is in the order of $250 million. "You could get a lot of family outreach workers for those dollars that were cut," he says. 

It remains unknown, however, whether any of the welter of investigations into Cody Fontaine's death will actually look at the relationship between tight budgets and his tragic death.

Ministry report 'won't be available'

Jeremy Berland, the assistant deputy minister of MCFD declined to speak specifically about the Cody Fontaine case, but told The Tyee that whenever a child dies, "we always review those circumstances."  Ministry investigators scrutinize calls received about the family, what services were provided, whether a child taken from a home was returned with appropriate family supports, and what kind of risk-reduction plan was in place, he said. 

The results of the internal investigation are confidential, Berland said, because they "will contain a lot of personal information about the family. We will make the recommendations and a kind of synopsis of the findings public. But the whole report won't be available."

Berland rejected any suggestion that a ministry investigation lacks sufficient independence to uncover systemic problems, such as the amount of services available to families, or the delivery of them.

"The fact that something happens doesn't mean, necessarily, something went wrong, and I think that we have to get away from the perspective that the only way to satisfy our grief about the death of a child is to conduct multiple inquiries," Berland said. "It's not, it doesn't help, it doesn't change the fact that these are very, very rare circumstances."

Coroner 'not a fault finding agency'

The Coroner's office, an independent body answering to the Attorney General, will investigate Cody Fontaine's death. Assistant deputy chief coroner Lisa Lapointe said a local coroner will investigate the circumstances of his death, assisted by personnel from the Child Death Review unit, ensuring "that if there are systemic issues, they are identified."  Recommendations to avoid future deaths form a key part of the coroner's report, but "the coroner's office is not a fault-finding agency," Lapointe noted. 

Lapointe said 80 percent of coroner's recommendations are accepted by the relevant agencies and government departments, but the coroner's office does not monitor whether or not these are actually implemented.  Even if a coroner believed a crucial recommendation was not being acted on, "the coroner doesn't advocate for changes because the coroner is in a quasi-judicial role." 

Until two years ago, B.C. had an independent Children's Commissioner who reviewed all cases of child deaths, natural, accidental, and criminal. "The coroner's report was one ingredient in what we looked at, but we also looked at things like systemic issues," the last commissioner, Paul Pallan, told The Tyee recently. Levels of government service, policies, and social work practices all came under Pallan's scrutiny in connection with a child death.  Any recommendations made by his office were monitored to ensure that they were acted on. "I personally had a high degree of commitment to it," he said. 

The Children's Commission Act gave the commissioner broad powers to investigate "the adequacy of services to the child or to examine public health and policy matters," conduct audits, made recommendations, review and resolve public complaints, educate the public and professionals, as well as to comment on matters of public policy.  Pallan said the scope of his investigations supplied him with hard data—ensuring that his advocacy on particular issues was grounded in solid evidence.

Rise and fall of Children's Commission

The Children's Commission was created in response to the Gove Inquiry into the death of Matthew Vaudreuil at the age of five, after a life of abuse and neglect—even though he and his mother were well-known to welfare authorities.  Justice Thomas Gove's  report was unanimously adopted by both the NDP government and the Liberal opposition; chief among his recommendations was the creation of a children's commissioner.

Gove made it clear that the commissioner should "comment publicly if the child welfare system does not respond adequately to a death or serious injury review."  Not a position for the feint of heart, the children's commissioner was charged with scrutinizing the work of politicians, bureaucrats, and social workers.  Being under the spotlight of the children's commission rankled some, Pallan says, "but to be fair, people who were mature and responsible in their roles accepted that." 

The Children's Commission was eliminated in 2002, just as the first wave of cuts hit the ministry.  A core services review by Jane Morley called for wholesale changes to the office, including removing its ability to investigate critical injuries, recommending policy changes on the basis of investigations of deaths and critical injuries, as well as audits of care plans; reviewing the circumstances of child deaths; investigating complains about services to children, among many others.  Jane Morley, who conducted the review, wrote, "I recommend that a part of the Children's Commission child fatality review function be transferred to the Coroner's office." 

In contrast to the practice of the Children's Commissioner, "the inquiry of the coroner need not include considering and commenting on services provided during the life of the child that were not causally connected to the child's death."  Morley also proposed having the ministry assume control of advocacy functions, aided by a children's officer who could "provide another, above the battle perspective." 

"Theoretically, that's not a bad position to take," Pallan said.  "The problem sometimes is that the system itself hasn't got to the point yet where it can be fully transparent and fully accountable, the way we would like it to be."

Jenkinson, of the BCSWA, mourns the loss of the Children's Commission, saying "the reports written were quite vigorous and challenging."  And it appears Gove did as well.  After the commission closed, and on the date of what would have been Matthew Vaudreil's 16th birthday, Oct. 3, 2002, Gove wrote to the Vancouver Sun.  "Who will do the comprehensive reviews of the deaths of children now that the Children's Commissioner has gone?  Who will independently advocate for children and youth without the Child Youth and Family Advocate?  Does our society have the resolve to prevent another Matthew?"

The position of Child and Youth Officer for B.C. was established last year, with Morley at its helm.  She is confident the coroner's report and an internal ministry review will root out any systemic inadequacies that may have led to Cody Fontaine's death.  Although the Attorney-General could ask her to specifically investigate it, she says her position is not, "primarily an investigative role."

'Never enough money'  

According to the website of the Child and Youth Officer Morley's mandate is "to comment publicly on issues affecting children and youth without interference from any ministry or from the premier and cabinet."  It is unclear, however, whether she will assess the effect of recent budget cuts on services for children and youth.  In her most recent annual report, Stay the Course, Morley notes, "Sufficient resources are a prerequisite for an effective service delivery system.  Yet there is never enough money to fund health education and welfare needs, including the needs of child welfare systems. This is the case not only in British Columbia, but also in the rest of Canada, North America and most of the world."

Although Morley said that she attempts "as much as possible to know what's going on in terms of services," the effects of losses to MCFD's budget over the past three years, are not the tack she's taking. "My view is that the most effective way that you're going to bring about effective, responsive services is at the community level, and that it is important to make sure that communities have resources that they need in order to do that," she said.  "But I don't think it's just a question of money.  I think it's a question of what are the best services and what are the best ways that they are to be organized."

Gordon Campbell in 1996

When Cody Fontaine was mauled to death, the premier was on vacation in Hawaii.  He has not yet commented on the incident, and his office referred The Tyee to MCFD for comment.  But when he was a member of the Opposition, Gordon Campbell unstintingly hammered on the issue of child deaths and the need for comprehensive, independent investigations of the model Gove proposed.  On Thursday afternoon July 25, 1996, he was particularly fiery. 

"Justice Gove was very clear. Justice Gove, hon. Speaker, said quite clearly that the death of every single child known to the minister or in the care of the ministry should be investigated promptly. It should be investigated in a way that we would be sure that it's thorough, so that we understand what's going on. I would just like to quote from the commission's report:

"Matthew's suffering and death was not unique. Many other children living in similar circumstances, known to the ministry through a child protection report or a request for services but not in the ministry's care, have died of unnatural causes. Some were killed by caregivers or other family members, some died in suspicious circumstances and some took their own lives.... They... are the 'invisible ones.' They died of abuse or neglect, alone and in obscurity."

On this side of the House, we agree that we should do everything we possibly can to prevent those occurrences from taking place -- every single thing. When a child dies, we should investigate. We should investigate independently. Again, Justice Gove was very clear on what he expected to take place -- what he said should take place and what has not taken place eight months after his report being tabled. He said quite clearly that a body should be established which will receive every report of a critical incident -- children who die or are seriously injured -- which should include any children who are in the care of the ministry or otherwise known to the ministry through a protection report or a request for services. Deaths and serious injury reviews should proceed promptly and should be coordinated with other investigations or proceedings.

The minister stood today and told us he is working with the coroner. Hon. speaker, we're not questioning the expertise of the coroner, but let's go back and look again at what we heard about review mechanisms external to the ministry. The coroner is specifically referred to on page 136 of Justice Gove's report. The coroner is no substitute for reviews. In 1993, 535 children in British Columbia age 19 or under died. The coroner, acting under section 9 of the Coroners Act, examined 312 of those deaths. In Matthew Vaudreuil's case, the report was a one-page report from the coroner."

Judith Ince is on staff of The Tyee.  [Tyee]

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