A jury that sat through eight days of evidence looking into how developmentally disabled people are cared for in British Columbia has recommended a complete overhaul of the system.
The jury was convened for a coroner’s inquest following the death of Florence Girard. Girard, who had Down syndrome, starved to death while in the care of a provincial government-funded home share provider in 2018.
In 2022, Girard’s caregiver, Astrid Dahl, was found guilty in B.C. Supreme Court of failing to provide the “necessaries of life” to Girard. She was found not guilty of criminal negligence.
The goal of the coroner’s inquest was to examine what happened and determine what lessons can be learned more broadly, rather than assign criminal blame.
The inquest jury delivered 13 recommendations to presiding coroner Donita Kuzma Friday afternoon.
The recommendations mostly focus on improving Community Living BC, the provincial Crown corporation responsible for supporting adults with developmental disabilities.
They include improving training and compensation for home share providers to meet the living wage and attract skilled workers; cutting down on layers of bureaucracy and putting those savings towards client-facing services; and improving how CLBC checks on the physical and mental health and quality of life of its clients.
In a statement posted Friday, CLBC said it “acknowledges that what happened to Florence Girard is absolutely devastating and should never have happened.” The Crown corporation said it welcomed the recommendations and that it is “committed to taking concrete actions to address them and to strengthen the delivery of home sharing services.”
Currently home care providers are required to hold a valid driver’s licence, obtain a criminal record check and do an hour of online training, said Tamara Taggart, president of the non-profit Down Syndrome BC. Taggart attended all eight days of the inquest.
The inquest highlighted how the systematic underfunding of the system and lack of training and supports for home share providers played a big part in Girard’s death, Taggart said.
Isolation, lack of oversight
In the years leading up to Girard’s death, she had developed osteoarthritis in her hip and needed a wheelchair to get around. But she was not provided with a wheelchair. Instead, she was placed on the top floor of a townhouse where she was effectively forced into isolation because she was unable to navigate the stairs.
Near the end of her life, Girard was sleeping on a mattress on the floor. The movie Titanic was played for her on repeat. She was served meals in her room. The window in her room had been blocked out by a dresser because she had been knocking on the window and yelling “hello” to people walking by, Taggart said.
“The last two years of Florence’s life were horrific,” Taggart said. “She didn’t starve to death in a week.”
“You think you know what 50 pounds looks like on a person. I thought I did, until I saw the police photos,” she added. “Those photos will haunt me for the rest of my life.”
Girard had been living with her home share provider, Dahl, since 2010. The home share was funded by CLBC, which contracted the local agency Simon Fraser Community Living, which in turn gave the funding to Dahl. Simon Fraser Community Living has since changed its name to Kinsight Community Society.
Someone from Kinsight visited Dahl’s home four times the month before Girard died without ever seeing her, Taggart said.
‘Caregiving is a job and we need to strengthen the workforce’
Some 4,300 adults with developmental disabilities in B.C. live in home shares.
Girard’s death and the jury’s recommendations are “an urgent call to action,” said Karim Ramji, a lawyer who worked as legal counsel for Girard’s sister, Sharon Bursey, and Down Syndrome BC during the inquest.
When reading out the recommendations, the chosen speaker for the jury used the word “immediately” six times.
“The jurors used that language to raise a flashing red light that means there’s a need for a total reset and overhaul of CLBC and how these individuals need to be properly cared for,” Ramji told The Tyee.
This is “not only for people living in care, but for the people who are caring for them,” Taggart added. “They go hand in hand. If a person caring for you is not well, then you won’t be either.”
Girard’s death and the coroner’s inquest have been a real “eye-opener” for people to learn how hard it is to be a care provider in B.C., Taggart said.
Home share providers in the province are considered contract workers. They do not receive benefits or vacation days, Taggart said. CLBC says people can have two respite days a month, but there’s never enough people to adequately cover that, she added.
“The jury made it clear that caregiving is a job and we need to strengthen the workforce,” Taggart said.
The jury recommended standardizing training, boosting pay to meet the living wage, offering higher pay for those looking after people with complex needs, and offering ongoing paid training so that caregivers understand how to best do their job and what their obligations are.
Taggart has a son with Down syndrome who requires full-time supervision and support.
She says she was pleased with the recommendation calling for family members to be supported at the same level as home share providers if they decide to care for their loved ones. She also appreciated the recommendation that families be included in the decision about whether or not to let individuals in care make their own health-care decisions.
Taggart told The Tyee that she knows from experience with her own son how important it is to have a long-term plan that includes the different specialists he’ll need to see throughout his life.
So she was also happy to see the recommendation, directed at the Ministry of Health and the Ministry of Social Development and Poverty Reduction, calling to improve ongoing health-care planning for those in care.
Taggart said she wanted to see the government follow the jury’s recommendations for “immediate” action.
“We know there are other people like Florence in care, and we’re talking about human beings, so the government doesn’t get to mull this over and spend millions to come up with a plan. People need immediate action,” she said.
‘I don't really know what it takes to lose your accreditation’
Taggart co-founded Down Syndrome BC after hearing about Girard’s death.
What started as a Facebook post quickly drew hundreds of emails of support and bloomed into a board of directors and registering as a non-profit society.
“The emails came fast and furious, with people saying they’ve been screaming into the abyss for years about this,” she said.
“Florence’s legacy needs to be systemic change,” Taggart said. “I have no intention of letting this go until we are satisfied as a community that there has been real change and the government has followed what the jury set out.”
Ramji noted how the recommendations are just that — recommendations. They are not binding in any way.
The CLBC has brushed off serious criticism in the past, he said.
In 2021 the Office of the Auditor General released a report that was “very critical of CLBC.” It found “the board of directors of CLBC had not been monitoring what CLBC was doing to ensure it was fulfilling its mandate to provide care to individuals who are developmentally disabled,” Ramji said.
In response the Crown corporation produced a strategic plan.
“I’d consider [the strategic plan] a promotional document, with no outcomes or measure of outcomes that in no way address the concerns raised in the auditor general’s report,” Ramji said. “Their response has been inadequate.”
In Friday’s statement, CLBC’s CEO, Ross Chilton, acknowledged that “the system and CLBC failed Florence” and that “the checks in place at that time didn’t work.”
Since Girard’s death, the statement continued, CLBC has improved its training, standards and policies, required contracting agencies to visit home sharing providers once every three months, and started checking that clients have a care plan that includes a doctor’s visit once a year.
Taggart says she wants to know why Kinsight Community Society is still accredited by the Commission on Accreditation of Rehabilitation Facilities.
All service providers need to be CARF-accredited to receive funding from CLBC, she said.
“Florence dies of starvation in their care, and they don’t lose their accreditation?” Taggart said.
Taggart pointed to a case in March 2024 when CLBC was supposed to be overseeing a developmentally disabled high-risk sex offender, and despite that supervision, an 11-year-old Kelowna girl was assaulted.
“I’ve checked, and the agencies they worked for still haven't lost their accreditation. So I don't really know what it takes to lose your accreditation, but it’s just ridiculous,” she said.
“Flo’s death can’t be in vain,” Ramji said. “There needs to be systemic change flowing from her death.”
Read more: Health, Rights + Justice
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