Another death review in Australia

In its annual review of child deaths, The Victoria (Australia) Child Death Review Committee finds problems with the child protection system in some rather predictable areas. These include:

1. Assessment is found to be inadequate in these cases. Fortunately, the committee sees that it is not just the workers but also the orhanziational context in which the assessment takes place.

We need to be asking are case loads too high, budgets avilable to get the work done, supports available to do the work? But there is also a problem with coordinating present and historical data to get a clearer pircture of what is going on in the family. This means that data must be coordinated from other agencies beyond child protection - a theme seen in so many of these inquireis.

As Eileen Munro notes in her work in England, there is also the need to be able to analyse the gathered data and come to realize what is and is not significant. This takes experience and good coaching from mentors and supervisors who have the time to spend with their colleagues.

2. The child's voice is often missed. If a child is not given the opportunity to tell what is going on from their perspective, then vital unformation is never heard. Too often workers give scant attention to that in these published cases. This has been seen for example, in teh Victoria Climbe case in Britain where no worker ever spent any significant time with that little girl.

As the Age media in Australia reports "THE deaths last year of 26 children known to Victoria's child protection authorities has highlighted staff shortages, inadequate training and poor assessment practices, a report has found."  Sounds way too familliar!

Those interested in reading the full report from Australia can go to http://www.ocsc.vic.gov.au/downloads/vcdrc/ar_vcdrc_2010.pdf

Another death reviewed

In Britain the case of Khyra Ishaq has not received the attention that the more famous child deaths have recived. Baby Peter and Victoria Climbie became household names there as the media laid bare mistake after mistake by child protection workers leading up to the deaths of these children. It was almost numbing to read the litany of errors - something that I have become quite interested in and will be writing a great deal about on this blog. There are many systemic reasons why these deaths occur but it is distressingly obvious that case workers are making the same errors again and again - in country after country.

We should be asking less why the workers are making the mistakes and more why the work environment, political system and community standards keep a system functioning in a way that these mistakes almost become inevitable.

Two years after Khyra's death, the Birmingahm Safeguarding Children Board has released their report on the death of Khyra. It was preventable.

What is different with this report is that the whole review has been released as opposed to the practice of the last few years where the serious case reviews only had the executive summary made publically available. This change represents a shift in direction in Britain, although it is unclear if that will be broadly done. Here in Canada, many reports are published in their entirety if they are made public - although that is not always the practice. There is a real debate about the value of showing the public all the facts as it risks making workers public targets as was seen in the case of Baby Peter where one of the workers has been publically vilified.

The 18 recommendations made in the Ishaq case are all too familiar - better assessment, better communication between agencies, better investigation, better monitoring, better training - recommednations that come out of the vast majority of these reviews.

The full report can be read at http://www.lscbbirmingham.org.uk/downloads/Case+14.pdf
Here is a summary that was published in the Herald Scotalnd newspaper:

Social workers could have saved starving Khyra, 7, report claims

• Khyra Ishaq: Died after suffering months of cruelty

heraldscotland staff

http://www.heraldscotland.com/news/crime-courts/social-workers-could-have-saved-starving-khyra-7-report-claims-1.1044342 accessed 2010 07 30

28 Jul 2010

A seven-year-old girl starved to death after a catalogue of missed opportunities by social services and other professionals, a review has found.

The report, by the Birmingham Safeguarding Children Board (BSCB), comes more than two years after Khyra Ishaq died at her home in the city.

Following months of starvation and cruelty at the hands of her mother and stepfather, Khyra died in May 2008 after contracting an infection.

But the report – published in full – found that her death could have been prevented, and occurred after the authorities simply lost sight of her.

Hilary Thompson, chairwoman of the BSCB, said: “The serious case review concludes that although the scale of the abuse inflicted would have been hard to predict, Khyra’s death was preventable.

“The report identifies missed opportunities, highlighting that better assessment and information-sharing by key organisations could have resulted in a different outcome.”

The 180-page document found that, despite concerns being raised by members of the public and school staff about Khyra’s welfare as far back as March 2006, information was not acted upon and safeguarding procedures were not properly followed.

It said: “There were a number of early missed opportunities for intervention by professionals.

“Three incidents during March 2006 were not progressed, either by failures of paperwork to reach the correct departments; failure to follow safeguarding procedures, or [failure] to conduct thorough checks.”

This resulted in any knowledge and intervention remaining purely single-agency at that stage.

The review, which began in May 2008, concluded: “Had there been better assessments and effective inter-agency communication over a period of time, Khyra’s death could have been prevented.”

A complaint of harrassment by Khyra’s mother, Angela Gordon, against a social worker who visited their Handsworth home in February 2008, generated a reluctance to complete an assessment, it was found.

The report said: “The complaint by the mother ... appeared to impact upon the Children’s Social Care manager and practitioner.

“This action generated a reluctance to follow through on plans with a partner agency to effectively pursue assessment procedures, for fear of repercussions.”

In March, Mr Justice Roderick Evans sentenced Khyra’s 35-year-old mother Angela Gordon, 35, to 15 years and jailed her former partner, Junaid Abuhamza, 31, indefinitely for the public’s protection, for a minimum of seven-and-a-half years. The pair were cleared of murder at Birmingham Crown Court but convicted of manslaughter.

When things go wrong - are we asking the right questions

Prof Eileen Munro from the London School of Economics has given consideration to what should we be looking for when things go very wrong in child proetction. The Jeffrey Baldwin story is one example but there are many more - some of which I will be writing about. It is distressing to read that a child has died because a social worker, foster parent or someone else in the child proetction system failed to proetct the child. It is, of course, easy to target the worker. But as Prof Munro notes, there are very real system problems that make it hard to protect children. As she states, social workers don't start their day out with the intention of letting a child die.

This video on YouTube is well worth the watch - rather short but very pointed:

http://www.youtube.com/watch?v=E4wREr5dN_Q

Does in home suppot work?

This is one of the most frequently used interventions to try and teach parents hwo to better do the job. Research has been mixed as to whether or not it works. There is thought that often it depends on the nature of the specific intervention. Research recently published has shown that well planned intervention can have a very positive impact. This type of intervention supports family preservation goals.  It may possibly reduce future costs arising from chronic re-opening of files and inter generational transmission of poor parenting practices leading to subsequent generations being within the child protection system. Here is a report published today through Science Daily which shows promis when the intervention also combines with therapy to address other related issues:

Abusive Mothers Improve Parenting After in-Home Training, Emotional Support of Therapists

ScienceDaily (July 27, 2010) — Mothers who live in poverty and who have abused their children can stop if they are taught parenting skills and given emotional support.

A new study has found that mothers in families in which there is a history of child abuse and neglect were able to reduce how much they cursed at, yelled at, slapped, spanked, hit or rejected their children after a series of home visits from therapists who taught them parenting skills.

There were large improvements in mothers' parenting in families that received the intensive services, compared to families that did not receive the services, according to SMU psychologists Ernest Jouriles and Renee McDonald at Southern Methodist University in Dallas, two of the study's eight authors.

As a result of the intensive, hands-on training, the women in the study said they felt they did a better job managing their children's behavior, said Jouriles and McDonald. The mothers also were observed to use better parenting strategies, and the families were less likely to be reported again for child abuse.

"Although there are many types of services for addressing child maltreatment, there is very little scientific data about whether the services actually work," said McDonald. "This study adds to our scientific knowledge and shows that this type of service can actually work."

Help for violent families

The parenting training is part of a program called Project Support, developed at the Family Research Center at SMU and designed to help children in severely violent families.

The study appears in the current issue of the quarterly Journal of Family Psychology. The article is titled "Improving Parenting in Families Referred for Child Maltreatment: A Randomized Controlled Trial Examining Effects of Project Support." SMU psychologist David Rosenfield also authored the study.

The research was funded by the federal Interagency Consortium on Violence Against Women and Violence Within the Family, along with the Texas-based Hogg Foundation for Mental Health.

"Child maltreatment is such an important and costly problem in our society that it seems imperative to make sure that our efforts -- and the tax dollars that pay for them -- are actually solving the problem," said Jouriles. He and McDonald are co-founders and co-directors of the SMU Family Research Center.

In 2007, U.S. child welfare agencies received more than 3 million reports of child abuse and neglect, totaling almost 6 million children, according to the U.S. Department of Health and Human Services.

Poor and single with children

The study worked with 35 families screened through the Texas child welfare agency Child Protective Services, CPS. The parents had abused or neglected their children at least once, but CPS determined it best the family stay together and receive services to improve parenting and end the maltreatment.

In all the families, the mother was legal guardian and primary caregiver and typically had three children. On average she was 28, single and had an annual income of $10,300. Children in the study ranged from 3 to 8 years old.

Half the families in the study received Project Support parenting education and support. The other half received CPS's conventional services.

New parenting skills + help

Mental health service providers met with the 17 Project Support families weekly in their homes for up to 6 months.

During that time, mothers, and often their husbands or partners, were taught 12 specific skills, including how to pay attention and play with their children, how to listen and comfort them, how to offer praise and positive attention, how to give appropriate instructions and commands, and how to respond to misbehavior.

Also, therapists provided the mothers with emotional support and helped them access materials and resources through community agencies as needed, such as food banks and Medicaid. The therapists also helped mothers evaluate the adequacy and safety of the family's living arrangements, the quality of their child-care arrangements and how to provide enough food with so little money.

Services provided to families receiving traditional child welfare services varied widely. The range of services included parenting classes at a church or agency, family therapy or individual counseling, videotaped parenting instruction, anger-management help, GED classes and contact by social workers in person or by phone.

Fewer recurrences of abuse

Only 5.9 percent of the families trained through Project Support were later referred to CPS for abuse, compared with almost 28 percent of the control group, the researchers found.

"The results of this study have important implications for the field of child maltreatment," said SMU's Rosenfield.

Project Support was launched in 1996 to address the mental health problems of maltreated children and children exposed to domestic violence, both of which often lead to considerable problems for children later in life, such as substance abuse, interpersonal violence and criminal activity. Previous studies have shown the program can improve children's psychological adjustment as well as mothers' ability to parent their children appropriately and effectively, according to the researchers.

Project Support: A promising practice

With funding from the U.S. Department of Justice's Office of Juvenile Justice and Delinquency Prevention, Project Support has been included in a study evaluating 15 "promising practices" nationally for helping children who live in violent families.

Jouriles is professor and chairman of the SMU Psychology Department. McDonald and Rosenfield are associate professors.

Other researchers were William Norwood, University of Houston; Laura Spiller, Midwestern State University; Nanette Stephens, University of Texas; Deborah Corbitt-Shindler, SMU; and Miriam Ehrensaft, City University of New York.

Jeffrey Baldwin - poorly thought out kinship care

Jeffrey Baldwin – DOB: January 20, 1997

Date of Death: November 30 2002

“On the last day of November in 2002, not quite two months before his sixth birthday, Jeffrey Baldwin died. He died from acute bacterial bronchial pneumonia with terminal septicemia, which occurred as a complication of prolonged starvation”. (R. v. Bottineau, para 1) With these words, Justice J. Watt of the Ontario Superior Court begins his decision in the criminal charges involving Elva Bottineau the grandmother of Jeffrey. She was also charged with unlawful confinement of Jeffrey’s sister Sibling J2 . Her common law husband, Norman Kidman had also been charged.

Jeffrey’s life was not long – just under 5 years. His last years were difficult and tragic. He came into the care of Elva Bottineau and Norman Kidman when he was only 5 or 6 months of age. When his life took the painful turn towards death is not clear from the public record.

The biological parents of Jeffrey his two older sisters and younger brother, Yvonne Kidman and Richard Baldwin had been found to be inadequate to the role of parent and child protection services had placed the children in the care of these grandparents. The children had been in the care of these grandparents from around April 1998. Sibling 1, their sister, came into the care of these grandparents December 6, 1995 and Sibling 2 in January 1999 not long after his apprehension at birth. Elva Bottineau had legal custody of Sibling 1 and she and Norman Kidman of Sibling 2.

In his decision, Justice Watt notes that the child protection authorities supported the placement of Sibling 3 and Jeffrey in this home.

Judge Watt notes:

133 Shortly after seven o'clock on the morning of November 30, 2002 Elva Bottineau called 911. She asked for a (police) car to be sent to 354 Woodfield. As she put it, somewhat matter of factly, "apparently my grandson is not breathing right now". She reported that her grandson was conscious, "a little", but he hadn't been eating well lately either.

134 In conversation with an emergency medical services operator, Ms. Bottineau speculated that her grandson might have choked on some food. She described his colour as red and white. He was also clammy, perhaps with a touch of the flu. In further discussions, Ms. Bottineau reported that Jeffrey was not breathing or making any sounds. She later said:

He does have a little bit of movement in him...

In his decision Judge Watt then goes on to describe what emergency service personnel then encountered:

136 Captain Royal Bradley of the Toronto Fire Department was in charge of the pumper unit that responded to Ms. Bottineau's 911 call. After some initial difficulty in getting a response to his knock, Captain Bradley and his crew entered the main floor of the residence. It was dark. He had to ask for lights to be turned on. Ms. Bottineau told him to keep his voice down because there was another child sleeping in the house.

137 Jeffrey Baldwin was laying on the kitchen counter on a towel. He was not breathing. He had no pulse.

138 On Captain Bradley's instructions, the two firefighters who had accompanied him, Paul Manning and David Merrifield, began CPR on Jeffrey Baldwin as he lay on the kitchen counter. Paul Manning could detect no pulse. He saw no signs of rigor mortis and none of post-mortem lividity.

139 Robert Selfridge, a level 3 paramedic, arrived at 354 Woodfield, along with his partner, Marc Dugas, at about 7:18 a.m. By then, Jeffrey Baldwin had already been removed and placed in the rear of the basic life support ambulance that was already outside 354 Woodfield when Selfridge and Dugas had arrived. Jeffrey Baldwin appeared very severely wasted. He was extremely malnourished. Selfridge could see the outline of Jeffrey's bones beneath his skin, especially around his ribcage and upper and lower legs. There was also a severe rash on Jeffrey Baldwin's abdomen.

140 Robert Selfridge detected no signs of cardiac activity. Jeffrey was not breathing. There was vomit in his airway. The attendant was unable to intubate Jeffrey to administer epinephrine. Selfridge's experience was that, even in cases where a person had recently died, some venous response usually occurred. There was none here. And there were no signs of life.

141 Marc Dugas, the level 2 paramedic who accompanied Robert Selfridge to 354 Woodfield, also failed to detect any signs of life in Jeffrey Baldwin. Jeffrey did not look like any five year old child that Dugas had ever seen before. He was much smaller and thinner than anyone Dugas had ever seen of equivalent age. He appeared emaciated, his ribs, tendons and veins standing out, visible to the naked eye. Jeffrey Baldwin's skin was mottled, almost like it was very bruised, and it was cold to the touch. Dugas could not establish an intravenous line. He noticed no signs of rigor mortis.

142 At about 7:26 a.m. on November 30, 2002 Jeffrey Baldwin was taken by ambulance to the Hospital for Sick Children. He arrived there at about 7:34 a.m. and was pronounced dead about ten minutes later.

189 In cross-examination, Paul Manning testified that Ms. Bottineau's calm, unemotional demeanour struck him as a bit strange. She did not offer the emergency crew any assistance, did not come outside to guide them into the house and told them not to turn on any lights once they were in.

In trial the pathologist outlines Jeffrey’s medical condition at death, stating (as reported by Judge Watts):

157 It was the evidence of Dr. Wilson that Jeffrey Baldwin was a stunted and wasted child. His height, ninety-three point five (93.5) centimetres, was below the third percentile for his age, thirty-three to thirty-five (33-35) percent below the average height of one hundred and fifteen centimetres for his age. His weight, nine point six eight (9.68) kilograms, was more than fifty percent below the average weight of twenty kilograms for his age. Jeffrey Baldwin suffered from marasmus, a general deficiency of energy, a caloric deficiency. He had received some proteins and carbohydrates, perhaps even fat in his diet, but not nearly enough to sustain life.

158 Dr. Wilson concluded that Jeffrey Baldwin died from acute bacterial bronchial pneumonia involving, as I have said, the upper and lower lobes of the left lung and the lower and middle lobes of the right lung, with terminal septicemia, occurring as a complication of prolonged starvation. At death, Jeffrey Baldwin was cachectic, in other words, in a state of severe malnutrition. His body mass was at only the twenty-fifth percentile for a year old boy and at the third percentile for an eighteen month old boy. His weight at death was less than half what would be normal for his age. In his first year of life, his height and weight were well within the normal range.

159 It was the evidence of Dr. Wilson that Jeffrey Baldwin's weight loss from chronic malnutrition was sufficiently severe that it would be expected to be fatal. His height related to normal body length for age as a percentage, known as "stunting", was eighty-one (81) percent, a nineteen (19) percent reduction, and his weight related to the weight of a normal child at his height, known as "wasting", was sixty-four point five (64.5) percent, a thirty-five point five (35.5) percent reduction. This stunting/wasting analysis indicates that, for Jeffrey Baldwin, the reduction in nutrition was both so extreme and so long-lasting, that not only did the deceased not grow appropriately in length for a child of his age, but his body weight for his reduced body length could not be maintained. Weight reduction of about thirty-five to forty percent compared to expected weight for the reduced length is reasonably expected to be fatal.

160 Dr. Wilson testified that the pneumonia from which Jeffrey Baldwin suffered was due to a mixture of Gram-positive and Gram-negative bacteria with predominantly fecal flora growing from lung culture and E-coli, amongst others, isolated from the blood culture. There were caked-on collections of bacteria on his skin. It is reasonable to conclude, according to Dr. Wilson, that the pneumonia developed from his extensive bacterial load from the skin through entry into the upper respiratory tract and then aspiration, carrying these organisms into the lower respiratory tract. This condition is not consistent with an incontinent child who has been bathed on a daily basis. Dr. Wilson had never before seen this degree or level of bacteria growth on the skin of a child.

161 The underlying cause of Jeffrey Baldwin's death, according to Dr. Wilson, was chronic severe protein-energy malnutrition. As a result, the deceased's resistance to bacterial pneumonia lessened. His state of hygiene probably contributed to the infection, which rapidly developed into fatal septicemia. There were no shaking injuries and no natural disease processes at work.

162 It was the evidence of Dr. Wilson that the chronic malnutrition and failure to grow happened in a period after Jeffrey Baldwin was eighteen months old and continued until the time he died. It would not have been possible for him to have weighed about forty pounds within a few months of his death. The malnutrition occurred over a very prolonged period, not just months but getting into years. His weight may have fluctuated from time to time, perhaps one or two pounds, but not substantially more. His appearance at thirteen months of age was normal, but it was not remotely so thereafter.

A pediatrician and nutritionist, Dr. S.H. Zlotkin also examined Jeffrey’s death. He states at trial as reported by Judge Watt:

173 Dr. Zlotkin concluded that when he died, Jeffrey Baldwin was both stunted and wasted.

174 He compared photographs of Jeffrey Baldwin taken at one year of age and at death. When he was one year old, Jeffrey Baldwin was a well-proportioned child with adequate fat in his arms, stomach, ankles and cheeks. He presented a technical picture of a healthy- looking child and showed adequate proportional linear growth. At death, he was severely, severely malnourished. There was no adipose tissue fat on his arms, legs, face, abdomen or chest. The tendons at the top of his legs were visible. So, too, the bones of his ribcage, and the outline of all the bones in his upper arms and legs. The colour of his hair, a shade of red, was indicative of chronic malnutrition.

175 It was the evidence of Dr. Zlotkin that he considered several possible explanations for the degree of growth failure he observed in Jeffrey Baldwin. Genetics were not a factor because Jeffrey showed normal growth in the first year of life. Further, five standard deviations below normal growth is not within the range expected from normal genetic variations.

176 Dr. Zlotkin also rejected environmental factors as an explanation for the degree of growth failure. These included both disease and non-disease states. The insult here occurred sometime between one year of age and death. There was no evidence that Jeffrey was stunted at six months of age, quite the contrary, but he was severely stunted at the time he died, only fifty percent of the expected median height for a boy his age. The insult here did not occur within weeks or months of death, or even a year. Weight-for-height is a better index of acute risk than weight-for-age, hence a greater value in identifying children who need nutritional treatment. Jeffrey Baldwin's weight-for-height ratio was sixty-seven point six (67.6) percent, a figure below the cut-off for severe malnutrition in developing countries. The Canadian standard is ninety percent. If a physician had observed the deceased's condition, he or she would have had the deceased admitted to hospital as an emergency patient.

177 It was the evidence of Dr. Zlotkin that, at death, Jeffrey Baldwin had the appearance of a textbook case of severe marasmus. He was severely malnourished. He was both stunted and wasted, suggestive of the chronic process that continued until his death. The etiology of the stunting and wasting was nutritional in origin. If the stunting had been secondary to endocrine or genetic causes, Dr. Zlotkin would have expected Jeffrey to have been stunted, but not wasted. The deceased suffered severe, long-standing malnutrition, very likely of nutritional origin. He had been chronically starved of food. Dr. Zlotkin could think of no alternative hypothesis to explain severe wasting and stunting.

178 Dr. Zlotkin also considered the prospect that some disease process, which interfered with either the digestion or absorption of food, or the metabolism of nutrients once absorbed, could have caused malnutrition, despite a reasonable food intake. The doctor concluded and rejected as influential:

i. cystic fibrosis;

ii. short-bowel syndrome;

iii. celiac disease;

iv. chronic diarrhea;

v. hyperthyroidism;

vi. HIV/AIDS;

vii. Kwashiorkor;

viii. chronic renal disease;

ix. chronic infectious disease; and

x. cancer,

among others.

179 It was the evidence of Dr. Zlotkin that Jeffrey Baldwin would have the same appearance he had at death ten days before he died and a similar appearance ten weeks earlier. He would have appeared slightly different ten months earlier, but his appearance would leave no doubt that he was severely stunted and severely wasted. There would only be a slight change in his stunting over a ten month period.

180 Dr. Zlotkin testified that persons who are mentally challenged have a sense of hunger and appetite. They have the ability and desire to eat. Over a very short period of time, a child may show his/her wishes by stopping eating. A meal or two, perhaps part of a day. But children, he testified, have a very strong mechanism of hunger. He considered that a description of Jeffrey Baldwin "eating like a horse" may have been accurate for the first year of his life, but was absolutely impossible and inconsistent with his appearance thereafter.

181 It was the evidence of Dr. Zlotkin that Jeffrey Baldwin would not have been able to interact with his environment in any meaningful way for weeks, even months before he died. As his death approached, Jeffrey would have been unable to walk or climb stairs. In the preceding months, he would have limited physical capacity and would tire easily because he lacked muscles.

Norman Kidman tells the police, as reported in trial:

208 During the interview, Norman Kidman told the police that he and Elva Bottineau had been together in a common law relationship for about thirty (30) years. He described when and how he and Ms. Bottineau got custody of their various grandchildren, including Jeffrey and Sibling 3. Mr. Kidman explained that Jeffrey, who was "borderline for mentally retarded", drank out of the toilet, peed and poohed and generally messed up his bedroom, and wasn't toilet-trained despite their best efforts. Jeffrey also banged his head on the floor and threw himself on the floor "if he gets mad".

He also states:

210 Norman Kidman explained that the bedroom Jeffrey shared with his sister, Sibling 2, had only two trunks and two beds. The other furnishings were removed because the deceased would wet and "pooh" himself and "put it all back in the dresser". He pointed out that Ms. Bottineau put the lock on the outside of the door to Jeffrey's and Sibling 2's bedroom. Its purpose was to prevent Jeffrey from getting up in the middle of the night and going to the bathroom and drinking out of the toilet bowl. The lock had only been on the door for about a month, perhaps not even that long. The lock had been on the door for, he said later, a year, for the same purpose. Ms. Bottineau unlocked the door each morning just before Mr. Kidman left for or about the time he left for work.

The trial evidence also shows the details of the world in which Jeffery and Sibling 2 lived in their bedroom.

212 Jeffrey and Sibling 2 occupied what has been designated "Bedroom #2" at 354 Woodfield Road. It is located on the upper floor between the bedroom, occupied by Norman Kidman, Elva Bottineau and Sibling J1, and the bathroom. To get to the Bottineau/Kidman bedroom from the first floor, a person would pass right by the door to the second bedroom. Likewise, on any trip to the bathroom from anywhere in the house, except from bedroom #3.

213 It was the evidence of Sergeant Farrugia that Elva Bottineau agreed to show police officers around 354 Woodfield, in particular, the bedroom occupied by the deceased and his sister. As they approached the door to the bedroom, Sergeant Farrugia noticed a hook and eye lock on the outside of the bedroom door. The lock was high up on the right-hand side as one faced the door, far enough from the floor that an adult would have to extend their arm and hand above their head to unlock it or lock it. Once engaged on the outside, a person inside the bedroom would be unable to get out.

214 Sergeant Farrugia testified that when Elva Bottineau opened the door to bedroom #2, there was a strong stench of urine in the room. The room was cold. There were two cribs, one against the wall with no linen on it, the other had the railing off, no sheets and two towels with what appeared to be fecal staining on them. There were two metal trunks and a similar number of white plastic bags on the floor. There was macaroni in a plastic bowl on one of the trunks. The room was unheated, despite Ms. Bottineau's claim that City Homes had been contacted about this problem.

215 Sergeant Farrugia also looked at the other bedrooms at 354 Woodfield. Both were warm and fully furnished. There were comforters on the beds and no smell of urine or feces in either room. Neither had a locking mechanism on the outside of the door.

216 Detective Constable Ian Kennedy also saw bedroom #2. Unlike the other bedrooms, there were no toys or other children's things in the room Sibling J2 and Jeffrey occupied.

217 Detective David Simpkins gave evidence that there was no carpet on the floor of Jeffrey and Sibling 2’s bedroom. He had never seen anything like it before in nearly three decades on the police force.

218 Police Constable Stephen Gibbons testified that bedroom #2 stood out from the rest of the house. It was harsh, dark, cold and damp and had about it an odour of both urine and feces. As he put it, bedroom #2 was a horrible room, not one in which he would expect anyone to live. The other bedrooms were brighter, cleaner, warmer and did not have a locking mechanism on the outside of the door.

219 Osiris Villalobos, an emergency after-hours worker with Catholic Children's Aid Society of Toronto, went to 354 Woodfield Road at about 12:30 p.m. on November 30, 2002. Sergeant Farrugia and the coroner, Dr. David Giddens, were there at the same time. Mr. Villalobos noticed the lock on the outside of the door of bedroom #2. He estimated that it had been installed about three-quarters of the way up the door from the floor. The odour of urine inside the room, he testified, was extremely heavy.

220 Mr. Villalobos gave evidence that he noticed the crib in the room with a couple of towels and a pair of sleepers, like those worn by a baby, on the mattress. There were a couple of bags filled with filthy diapers in the middle of the room. The uncarpeted floor was heavily water or urine-stained. One of the mattresses was soaking wet, apparently with urine, and there were splattered dry feces on the surface. There was filthy clothing on top of the towels. The overall appearance of the room was "extremely shocking". The bedroom was "freezing cold". There was no heat coming from the vent on the common wall with the bathroom. There was another mattress in the room apparently unused. Mr. Villalobos saw no toys or children's clothing in the room.

221 It was the evidence of Mr. Villalobos that the other rooms in the house were warm, comfortable and appropriately furnished. Mr. Villalobos decided to apprehend all of the children who remained in the house.

222 Dr. David Giddens described bedroom #2 as very cold. The uncarpeted wooden floor was stained. There was no heat from the floor vent. There were no decorations, only a single unwrapped toy. There was no sheet on the mattress in the crib. The mattress was stained and had feces on it. The smell of urine was overwhelming. The rest of the house appeared normal.

223 Derek Freestone moved in 354 Woodfield Road in October 2003. He readied the premises for winter. He noticed that the second bedroom was colder, so he caulked around the baseboards and fixed the vent so that it would remain open. Mr. Freestone also opened the valve in the basement heat duct and fixed it to ensure that it remained open. The room warmed up substantially.

224 It is common ground that City Homes, the landlord at 354 Woodfield, had never received a complaint about lack of heat in bedroom 2 during the Bottineau/Kidman tenancy.

In the decision, we also see one of the ways in which these cases can involve medical practitioners:

226 It was the evidence of Dr. Alladin that he saw Sibling 1 twenty-seven times between January 6, 1994 and March, 2000. Sibling 2 attended twenty-three times between December, 1995 and March, 1998. Sibling 2 was seen ten times between October, 1998 and February 26, 2001. On one occasion, Sibling 2 was hospitalized for whooping cough.

227 Dr. Alladin testified that he saw Jeffrey Baldwin on seven occasions from June 10, 1997, when Jeffrey was four (4) months old, until June 22, 1998, when he was a year older. In July, 1997 Jeffrey weighed seventeen pounds five ounces and was twenty-eight and one half (28 1/2) inches long. About seven months later, in February, 1998 when Jeffrey was thirteen months old, he weighed twenty-two pounds.

228 On March 12, 1998, Elva Bottineau brought Jeffrey to see Dr. Alladin after she had been awarded custody of her grandson. Dr. Alladin referred the child to a paediatric neurologist at the Hospital for Sick Children. Ms. Bottineau reported on the hospital visit when she brought Jeffrey back to Dr. Alladin for the last time on June 22, 1998. She made no mention of any diagnosis of Jeffrey as "borderline mentally retarded", nor did she say anything about him banging his head. At that time, Jeffrey was a healthy boy who was meeting his growth milestones.

229 Dr. Andrew Wong also practiced medicine at the Raxlen Clinic. Norman Kidman had been his patient for a few years. Elva Bottineau, Sibling 2 and Sibling 3 Kidman had also been his patients. Dr. Wong never saw either Sibling 2 or Jeffrey Baldwin as patients.

230 It was the evidence of Dr. Wong that on September 10, 2001 he saw both Elva Bottineau and Norman Kidman in his office at the clinic. They spoke to him about what they described as Jeffrey's mental retardation and behavioural problems. Jeffrey was not there. Dr. Wong was not sure who provided the background information, but he thought it more likely that Norman Kidman did because he had been a patient longer and the doctor knew him better. At all events, Dr. Wong learned that the couple had become Jeffrey's guardians about two years earlier. According to their story, a paediatrician who had examined Jeffrey had said that he was "borderline mentally retarded". The child was not toilet trained, would not sit on a potty, was disruptive, could only understand simple commands and was limited in his speech. Dr. Wong advised the couple to be patient, but firm with him. The doctor offered to refer the child to a paediatrician if the condition persisted.

231 Dr. Wong testified that if either Elva Bottineau or Norman Kidman had made any specific complaints about Jeffrey's behaviour, for example, that he deliberately banged his head, drank out of a toilet bowl or spread feces around after soiling himself, he would have noted such abnormal behaviour. He had no such notes. He would not have suggested that rebelliousness was at the root of the problem.

232 Dr. Wong never saw Jeffrey Baldwin as a patient. Had the child presented, as in the post-mortem photographs 18A-18C, Dr. Wong would have sent Jeffrey straight to the hospital and reported his condition to the police and child welfare authorities.

233 Dr. Dirk Webster Huyer is familiar with the medical aspects of child maltreatment, including evaluation, interpretation of injuries and the medical consequences of certain findings made on examination.

234 On January 20, 1997 he examined Jeffrey Baldwin, who had apparently been shaken or otherwise handled roughly at thirteen months of age. Dr. Huyer found no rib fractures or other physical abnormalities. Jeffrey was irritable on examination, but Dr. Huyer considered the chief reason to be two ear infections and a cold.

235 Dr. Huyer had no recollection of any consultation with Jeffrey's grandparents in which he advised them that Jeffrey was "mentally retarded". At all events, he would not use such terminology, rather would describe the child as "developmentally delayed" or challenged. He would have resolved any concern he had about developmental delay by specific testing in occupational or developmental therapy.

Summing up the cause of death, Judge Watt states,

It is incontrovertible on the uncontradicted evidence of Doctors Wilson and Zlotkin that Jeffrey Baldwin died of acute bronchial pneumonia, which involved the upper and lower lobes of his left lung and lower and middle lobes of his right lung, with terminal septicemia, which occurred as a complication of prolonged starvation. The stunting and wasting visible at death permits of no rational conclusion other than Jeffrey Baldwin was chronically starved of food over a very long time. (par. 267)

He also makes it clear that the risk of child welfare authorities was well understood by Elva Bottineau stating:

280 It was the evidence of James Mills that on two or three occasions prior to the evening of November 29 and morning of November 30, 2002 he hd suggested to Elva Bottineau that Jeffrey Baldwin should be taken to the hospital. Each time, Ms. Bottineau quickly changed the subject. She made it clear that she did not want to talk about it. Her expressed fear of hospital attendance was that hospital authorities would contact the CAS and she would lose the children, more specifically, the money she received for taking care of them as their guardian.

It turns out that in February 1979, a psychologist assessed Elva Bottineau for family court. She testified at the criminal proceedings. Justice Watt notes of her testimony regarding the 1979 assessment:

311 In further cross-examination, Dr. Bray testified that Elva Bottineau would have great difficulty taking care of children. She was not able to parent adequately and had no appreciation of the risks she took with others. The demands of children were likely, according to Dr. Bray, to be beyond her capabilities.

The CBC program, The Fifth Estate examined the Jeffrey Baldwin case. What became apparent from that investigation is that the Bottineau – Kidman family was indeed known to child protection services. What then becomes relevant is that, within their files, child protection had evidence of the prior criminal convictions for child abuse of each of these grandparents. Elva Bottineau was convicted in June 1970 of assaulting her then 5 month old daughter. There is also the prior parenting capacity assessment which suggested that this grandmother was not capable of assuming the role of parent.

It is also clear that there were several other adults living in the home who appeared to either turn a blind eye to what was going on or chose to ignore it for risk of placing their own living accommodations at risk. In total there were six adults and six children.

The Fifth Estate story also made it clear that there were various professionals in the home for various reasons. Yet none appeared to have taken any notice of the situation with Sibling 2 and Jeffery although it appears probable that Elva Bottineau would take steps to avoid these children being seen and putting her kinship care resources at risk.

This case also raised that there may have been other professional eyes outside the home. An example is a teacher who saw Sibling 2. At trial Justice Watt states:

497 In cross-examination, Mr. Garrido acknowledged that he did not report Sibling 2s condition to anyone. He thought that the educational assistant or home room teacher would do so. He agreed that it was not unusual to see children at the school who were dirty.

499 In Ms. Revoredo's classroom there is a snack table. The snacks, which are provided, include vegetables, drinks and fruit in fixed portions. Students are allowed seconds and sometimes thirds. Sibling  2 asked for seconds, sometimes thirds when they were available.

500 In cross-examination, Ms. Revoredo recalled that Elva Bottineau, Sibling 2s guardian, came to school on occasion and did volunteer work in Sibling 1s class. She did not do the same for Sibling 2.

501 Helen Voikos was an education assistant in both junior and senior kindergarten classes at Roden Public School in the Fall, 2002. Sibling 2 was a student who wanted lots of attention. She frequently sought help from Ms. Voikos and followed her around the room. She was always hungry. Ms. Voikos noticed a very strong smell of urine coming from Sibling  2. The smell, which Ms. Voikos noticed a couple of times, perhaps more, was strong enough that other children would sometimes not play with Sibling 2. To be enrolled in school, a child must be toilet-trained.

This helps us to see one of the other challenges and that is – who will take responsibility for raising the flag of concern. Indeed, at what point is the problem big enough to warrant indicating concern.

The Fifth Estate also managed to track down an older child of Elva Bottineau. What he tells is that the treatment of Jeffrey may not have been out of character for her. He tells of an abusive childhood that included being locked up.

As so often happens in these cases, the information that becomes available after the fact is disturbing indeed. Testifying at the trial, the foster mother describes that there was clearly a difference between the two siblings who appear to have been treated differently by the grandparents and little Sibling 2. She stated that these other siblings were horrified that they had to sit at the same table as, what Sibling 2 became known as in the grandparental home, one of the pigs. Canwest news services reported from the rial on November 3 2005:

The first night the children arrived, the woman said she observed the oldest sister was "horrified'' she had to sit at the same dinner table as her youngest sister.

"Pigs eat on the floor. Pigs don't share the table,'' the oldest sister said.

The younger sister and Jeffrey were allegedly kept locked in the same bedroom and allowed to eat only after everyone else in the home had finished.

There has been evidence the two children were forced to sit in front of a kitchen wall for lengthy periods of time as punishment. The younger brother of Jeffrey, reportedly asked the foster mother "where the pigs' wall was,'' and added that his "old home'' had a "wall of pigs.''

A few days after the children were placed in her care, the foster mother said she noticed the younger brother didn't flush the toilet. When she asked him why it was important to flush the toilet, she said he replied, "so pigs don't drink piss and shit water.''

The foster mother was shocked to see the younger sister try to drink from the toilet bowl.

"I stopped her immediately,'' the witness said

The foster mother also reported that the older sister said that it was obvious Jeffrey would die and wondered why child protection had not come to his rescue. This story is repeated by the foster mother to the Fifth Estate. Jeffrey and the sister that were abused were referred to as “pig” who ate at the pig wall from the pig bowl and slept in the pig room. The sister who did survive the abuse was seen by the foster mother to have many physical issues likely arising from her own abuse. The evidence also is that these two children were denied many of the normal developmental opportunities that most children had such as playing outside. Exercise for them was walking around the kitchen and, if they stopped, having objects thrown at them.

What is an important practice issue is what is known to the supervising agency. Jeffrey and his siblings went to live with their grandparents on a private guardianship basis but with the knowledge and apparent approval of child protection. What did not appear to occur, and was apparently admitted to by the CPS, is that they did not check their own records which did include the prior convictions of both grandparents.

At times when caseloads are high, budgets restrained, the time necessary to dig out old records and consider how that information might apply to present circumstances can seem like an unnecessary burden. What can be seen in this case is that can lead to disastrous outcomes. There is an arguable case that the children should not have been placed in this kinship care until the grandparents had been properly vetted. Yet, it is probable that kinship care placements are occurring frequently with only tacit if any review by child protection. It can also be argued that this works out in most cases.

Casework is not about what works most of the time but about what needs to occur in the particular case in front of the social worker. This makes case work hard as there is a need to know as much of the relevant history as possible without getting bogged down in details. You must sift through information deciding what really matters and how has the past history offered lessons about what is likely in the present.

Thus, from this case we learn several valuable practice lessons:

• Past history is quite relevant and may be difficult to access. It opens up the questions about what has occurred before and what is or is not different today.

• Children have a particular relationship with their caregivers which may be unique to that experienced by the other children. There is often a target child.

• Kinship care may not be better. It requires assessment on its merits on a case by case basis.

• There may be several professionals involved in a child’s life that have concerns but no one professional feels that what they know, in isolation, represents enough to warrant involvement of child protection.

• Those who are abusive may well know that they need to keep the secret and know that involvement of child protection will be detrimental. They are effective at keeping information away from CPS even during home visits. Thus, social workers need to be thorough in their reviews including interviewing other children in the home and seeing the entire living environment.

• It is poor case planning to believe that other adults in the home act as another set of eyes and will be concerned about what may be happening.

• Alleged facts offered by caregivers require independent verification.

• Much information may be available after the fact but case decisions are made with partial information.

• Risk assessment is based upon what is currently known and therefore requires review when new information becomes available.

Note that numbered paragraphs are from the decision of the judge in the Ontario Superior Court in respect of R. v. Bottineau and Kidman. 

Protection v Family Preservation

On a daily basis child protection workers are faced with the dilemma of protecting a child while trying to preserve families. It can be an almost impossible dilemma in certain situations.


Of course, the vast majority of children are raised in families which are good or at least good enough. There are a smaller number of families where, with supports, they can be made good enough. Then there are those where the child cannot be safely maintained in the home but successful interventions can be brought to bear that will bring the family up to good enough and the child can be returned. There is a small number of cases where that cannot be the case. In those cases, parental rights need to be terminated.

Even in the latter cases, there can be open adoptions, long term foster care with access and kinship care options that allow children to be still connected to biological family. There are cases where biological family is just too unhealthy for contact even though children often still seek to find ways to have contact.

Family preservation has strong political forces on its side - and so it should for the majority of cases. But one needs to question where that line should be dropped. Are we trying to preserve families in cases where termination is in the child's best interests? Are we trying so hard to preserve families that we are seeing children come and go from foster care as parents improve, relapse, improve, relapse, improve, relapse yet again. This is foster care yo-yoing and can hardly be seen as beneficial.

Research in England recently published suggests that we need to get the decision in place as soon as possible and not drag the child through multiple placements through yo-yoing or other actions that do not create stability for the child.

The more a child is left in chaos, the harder many children find it to self regulate. The more placements, the harder it is for a child to be stable. For sure, there are many examples of children who go through many placements because of poor case management - a subject of a future post.

Child protection must understand that best interests of the child must also mean that they may not be able to preserve a child in their biological family when that family cannot be made good enough. Family preservation does not mean preserve at any cost.

This is pretty controversial as many critics of child protection point out the children who are harmed in foster care. Those problems too need addressing and future posts will address other fallings of the system.

Legislation

The majority of child protection legislation in western societies focuses on family preservation. This reflects the moral foundation that the family is the best place to raise a child and the family is the foundational unit of the society. For the vast majority of children, this is a true statement. While most of us can look back on the family we grew up within from a critical perspective saying, "Oh, I wish mom or dad had done... or not done...", we still view our childhoods as essentially good experiences.
This is something that most clinicians need to remember as we spend much of our time with children and adults who have not had those experiences. We see people whose childhoods have typically been less than ideal. Those of us working in the realm of child protection tend to see people whose lives have been very negatively impacted by lives in families of origin.
Yet it is that very reality that legislation must also consider - those familes that are not safe and cannot be made safe. These families are the ones where addiction, abuse, domestic violence, substance abuse, chronic menatl health issues are the profound themes of life. Nurturance, attachment, care and attention are greatly diminished or absent.
Children in foster care often come from homes where these problems abound. Legislation rightly directs child protection authorities to try to change what is going on - to see what can be done to make the family at least good enough and thus, preserve the family unit. A noble goal that works in many cases.
Legislation typically considers those cases where change is not possible and raises ways for courts to consider termination of parental rights(TPR). One of the major challenges for child protection is when to give up on the family and seek solutions for children in foster care, kinship care or adoption.
Critics of TPR point to research such as that being done by Chapin Hill that shows that long term outcomes for children aging out from foster care don't od that well in social and economic terms. But then children growing up in these highly deficient families don't do that well either.
So what is the balance? This is a delicate question but those who criticize TPR and those with a more conservative view believe that family preservation is something of a holy grail and that you should almost never give up on the family unit except in the most extreme cases. Where is the line to be drawn?
This is the challeneg of child protection on a daily basis - case by case; child by child. Family preservation is important but should we be making valiant efforts? If the child has spent almost as much time if not more of their lives in foster care than with their biological family, what are we trying to preserve? If the parents have chronic problems that seem resistant to change such as frequent substance abuse relapses, what are we requiring the child to endure in order to preserve the family unit? If despite interventions, parenting capacity remains poor, can we accept that the parent just can't do the job? These are difficult questions. Legislation and the moral agenda of government and society sways the clinical decision making. Should it?

Why this blog

I have been a social worker in various roles for over 30 years - a great deal of it working with individuals who have involvement in the child protection systems. In addition, I teach part time at Mount Royal University in Calgary, Alberta. I have become quite interested in why does the system work many times yet there are repeated errors that occur which lead to serious losses including the dealths of children involved with the system.

I have begun assembling data from published reports in England, Canada, USA, Australia and New Zealand. This includes serious case reviews, commissions of inquiry and other formal reviews as well as reports in both the academic press and the mainstream media. When looked at as a whole they start to form a distressing pattern seen in each of these countries. For sure, there are many examples of where the systems have worked - I have seen it in my work. But we must continue to examine those situations where the chidlren are dying - why and what can be done about it.

There are other voices for reform - those who are very critical of child protection agencies and those who feel that the systems do not go far enough - particularly when a child dies.

In this forum, I intend to consider data as it becomes available but also look at the many themes seen in the cumuluative body of work. I will try to post at least weekly and also to encourage controversial views.