They could have lived

The British Columbia Representative for Children and Youth, Mary Ellen Turpel-Lafond, has yet again delivered a thoughtful critique of a case where children have died who were known the the province's child protection system. The report titled  Honouring Kaitlynne, Max and Cordon: Make Their Voices Heard Now looks at the case of the three children murdered by their father, Allan Schoenborn who now remains in a forensic psychiatric unit having been found not criminally responsible due to a mental illness. The report tells the story of children exposed to domestic violence, untreated mental illness and addictions.

The story is one of multiple involvements that included child protection, mental health and police in what might be seen as poorly coordinated interventions that yielded weak protection for the children. This is a story that is often repeated. We have seen many cases in various jurisdictions where poor communication and poor coordination between agencies have resulted in families not receiving the help needed. The result has been the death of children.

The story also includes situations where data was available but not acted upon. Again, a theme that is familiar to those who have looked at these death reviews.

Turpel-Lafond also notes that child protection in this case failed to consider the domestic violence implications of the case. As she states:

Too often, ministry social workers did not apply a domestic violence lens or use their own domestic violence guidelines in dealing with this family...The children’s mother was sinking into depression, despair and anxiety. She was not given concrete suggestions or strategies or connected with appropriate supports on how to protect her children or how to keep Schoenborn away from the home, except to call police if he showed up. Workers repeatedly told RCY investigators that they had no training in working with families experiencing domestic violence, and this is evidenced in the poor practice and approach they took with the children’s mother. (p.2).

 The lack of coordination can be seen when The Representative states:

The various systems involved with the family were not aware of the severity of Schoenborn’s mental illness and substance abuse because he was not interviewed from these perspectives by police, corrections or child protection. Also, there was very little collaboration or information sharing among these systems. p.3

As was seen in the Matthew John Vaudreuil  case in 1995, also in British Columbia, Turpel-Lafon creates a chart that shows just how many different times child protection, justice and other systems were involved. There was clearly no lack of eyes on the family - what there appears to have been was a lack of effective interventions.

Turpel-Lafond's report is worth reading if only because she also lays out the ways in which the mother of the children behaved in almost classic ways as an abused women. She would recant allegations, seek to have orders lifted and show signs of being enmeshed into the patterns of a sick, abusive husband.

There is also a pattern of multiple child protection workers along with family moving. This meant that there was inconsistent case management. Case management between child protection and the justice system was, at times, also in conflict.

On p. 58 of the report, The Representative sums up the issues stating:

hese children were extremely vulnerable to violence and harm due to the domestic violence in their home, and their father’s untreated mental illness. Countless opportunities to ensure that the children and their mother were safe were missed because of a profound lack of coordination among the child-serving, mental health and criminal justice systems over many years, compounded by glaring failures in child protection practice, and an inability to recognize and assess the extent of the father’s mental illness.

As this report and many that have gone before, note that different systems, child protection, justice, mental health, have different priorities and thus approach cases from those varying perspectives. Unless there is good communication, co-ordinated  case planning and common training on common topics, there will be further failures to protect children.

In my own practice, I come across communication barriers often. The Velasquez review in Alberta highlighted this as a concern and notes that information silos can hamper good child protection. This appears to again be an issue in this review.

The review closes with an appendix that offers 8 steps that should be considered in domestic violence cases:

Keeping Women Safe: Eight critical components of an effective justice response to domestic violence

The following critical components are needed for an effective, specialized response to domestic violence:

1) Managing risk and victim safety – comprehensive, coordinated approach to risk and safety assessment and victim safety planning

2) Offender accountability – appropriate and consistent sentencing, enforcement of protection orders, and accessible treatment for abusers

3) Specialized victim support – comprehensive, proactive, and timely support with outreach and access for marginalized groups

4) Information sharing – consistent, timely information sharing between agencies and with the victim

5) Coordination – coordination and collaboration at all levels among relevant sectors

6) Domestic violence policy – consistent informed approach to charging, prosecution, and offender accountability

7) Use of specialized expertise – dedicated justice system personnel, court time and specialized training

8) Monitoring and evaluation – integral part of all the critical components and a systematic, comprehensive approach to collection, analysis, and publication of statistics across all justice system components

Source: Critical Components Project Team-Light, L., Ruebsaht, G., Turner, D., Novakawski, M., Walsh, W. (2008). Keeping women safe: Eight critical components of an effective justice response to domestic violence.