Government, agencies failed Alex Gervais, says Representative for Children and Youth. Photo from Dylan Pelley/Facebook. Alex Gervais’s suicide was “a predictable outcome of his journey through the child welfare system,” according to a report from the province’s Representative for Children and Youth. Gervais was in the care of British Columbia’s Ministry of Children and Family Development when he jumped from a window in an Abbotsford Super 8 motel where he had been living. Through 71 pages, “Broken Promises: Alex’s Story” traces Gervais’ story from his birth to two parents who suffered mental illness, through years of interactions with child protection services in two provinces, to his suicide in 2015 at 18. “Constant destabilizing ministry-initiated moves during his early life, along with lost opportunities for him to have found permanence with extended family or a connection to his Métis culture, left him with a burden of trauma that was never addressed,” the report from acting representative Bernard Richard said. “Clearly Alex's death was a tragedy that could have and should have been avoided,” Richard told reporters Monday morning. “I do have a greater concern for the hundreds of other kids in the system that are served in exactly the same way.” Gervais’ story included repeated abuse and a failure to provide care for his mental health issues. “Multiple placements stripped him of attachments and connections that are the basic need and right of every child,” it found. At 10, he moved into the care of an agency under contract to the ministry, which gave the “illusion” of stability, the report said. But the social workers who were to care for Gervais tended to ignore him while struggling to cope with others in their caseloads whose needs seemed more urgent. “Left without secure attachments or an education that could have prepared him for some future success, it is unsurprising that Alex turned to substance use,” the report said. “His final weeks in care, as he faced aging out with no plan in place and a largely absent ‘caregiver,’ were a nightmarish combination of heavy substance use coupled with Alex’s own overwhelming sense of abandonment.” The report is intended to help prevent other children and youth from experiencing a similar fate, it said. “When a child is taken into care for his own protection, it is the responsibility of government to fulfill the role of the ‘prudent parent,’” it said. That means meeting the child’s needs for a stable home, nurturing relationships and experiences, enough food, suitable clothing, education, medical care and a meaningful connection to his culture. “In Alex’s case, the services he actually received fell far short of the care we expect from any parent in British Columbia,” said the report. “Instead, he was left to drift through the care of the provincial Ministry of Children and Family Development, living in 17 different placements and under the watch of a total of 23 different social workers and caregivers after being removed from his birth family. At the very end, Alex was alone.” Richard said the province's Auditor General is looking at the ministry’s use of contracted services. There are about 100 agencies under contract to look after 700 of the children and youth in government care. But as those contractors enter deals with subcontractors, the government has little way of knowing which are providing good services and which are not, he said. “In the end in Alex’s case, and I fear in other cases as I’ve said, the least qualified caregivers in the province are providing care to the most needy youth and that's really not acceptable,” he said. “If we don't do the job right, these kids will end up costing us millions of dollars in any event.” Stephanie Cadieux, the minister of children and family development, said “Alex’s story is undeniably painful to read.” She said she agreed with the findings and the government accepts all Richard’s recommendations. “If I'd written the report, it would say the same thing,” she said. “There was a series of problems and they go back many, many years.” While there is obviously much work to do, Cadieux said, “What I can offer is change to the system, more social workers, strengthened oversight and increased accountability. It’s what we’ve been doing and what we’ll continue to do under my watch.” The problem in Gervais’ case was not a lack of resources, but inappropriate resources, she said. More needs to be done to provide families and foster families with resources and to ensure children and youth in care maintain a connection to the culture they come from, she said. Cadieux said the government has added 200 staff in recent years and will add 100 more in the fiscal year of 2017-18. Since Jan. 1, all 700 children and youth being looked after in residences run by contractors have had a home visit from a social worker, she said. The government has committed to making sure all of the 7,000 children and youth in care have the required plans for their care, she said. In a statement, NDP leader John Horgan said the government missed an opportunity to create a safe and caring home for Gervais. “Alex needed their help and Alex begged for their help,” he said. “There are no excuses for this,” Horgan said. “Christy Clark has replaced safe, well-trained caregivers with for-profit contractors, and it’s not working. The most vulnerable youth in care are paying the price.” He said investing the right resources at the right time would save lives. The report made four recommendations: That when children or youth in care are unable to live with their birth families, the ministry of children and family development provide the necessary support for them to “achieve permanency” with extended family or another adult who they have a positive connection with. That includes providing support such as respite care and making sure social workers have the time to pursue such placements; That the ministry follow previous recommendations from the previous Representative for Children and Youth Mary Ellen Turpel-Lafond and Grand Chief Ed John “to bring Care Plans into compliance with standards already called for in legislation and policy,” including making sure all indigenous children and youth in care have “a robust cultural plan connecting them to their Indigenous heritage”; That the ministry “take immediate steps to ensure that children and youth in care who have been identified with mental health needs receive timely and uninterrupted mental health services, regardless of any changing circumstances in their lives, including changes in placements”; and That the ministry make it the highest priority to “significantly enhance” the oversight it conducts to ensure quality and financial accountability from the agencies it contracts to provide residential care for children and youth. “When tragedy occurs, it is our responsibility as a society to learn lessons and make the changes required to prevent similar occurrences,” the report said. “The Representative expects government to learn from Alex’s story and to take these necessary steps.” * Story updated Feb. 6, 2017 at 1:31 p.m.