The policy debate that should come out of the death of Alex Radita

Canadian media is covering the current trail of Emil and Rodica Radita for the first degree murder of their 15 year old son Alex. The allegations involve medical neglect of their son's diabetes leading to his death. The family is reported to have been involved in child protection systems in British Columbia and Ontario prior to his death in Alberta.

Much has been made of the supposed failure of British Columbia social workers to notify their counter parts in Alberta when they learned the family had moved left B.C. They had found out about the move as they were looking for the family when it became apparent they were not following through with Alex's medical care.

There has also been significant criticism of a judge in B.C. for returning Alex to parental care even when the child protection workers and specialists were arguing against it. National Post columnist Christie Blatchford has been quite critical of that decision and the failure of B.C. social workers to follow up with Alberta.

Alex Radita at age 15 (Source: Calgary Herald from photos released by the Court)

Child protection systems are often criticized for their failure to effectively communicate with agencies. It is a theme that has cropped up in most of the 91 public reviews I have examined in Canada. It is also very common in reviews in other countries.

There is an issue that needs discussing in Canada though, but also in countries such as the United States. Canada's constitution places control of child protection within provincial and territorial jurisdiction (there are specific aspects that are different for Aboriginal on reserve families but that is for another post). Health care and child protection legal processes also fall under provincial jurisdiction. Thus, each province and territory operates their own system, except for Ontario which places delivery of child protection into a complex network of children's aid societies following provincial legislation.

What this means is there is no national child protection system. It is a series of unique systems. Each jurisdiction has its own legislation, policy, procedures and service delivery mechanism. There is  no national requirement for data sharing. Families can and do move between jurisdictions to avoid continuing scrutiny by child protection. They are quite able to do so once their case in one province is no longer active.

When a case opens in one area, families are asked about their history elsewhere but there is no national database to work from. Should there be? Protagonists of data sharing might well argue for one but those who argue for protection of information and privacy might well make an alternative argument. Child protection legislators and senior managers across Canada might well take the Radita case as an opening for a national discussion. I want to emphasize that many of the workers I know make efforts to learn about families past participation in other parts of the country.

The Radita case raises some important policy issues and we should not let the chance pass. Another one is about legal duty of care. Like the Jeffrey Baldwin case in Ontario, it appears there were other adult children in the Radita home. Yet the criminal code does not place a duty of care on those who are not parents or legal guardians. Thus, other adults in the home who were aware Alex and Jeffrey were at risk cannot be held accountable . That too should be reconsidered.

It is important to note that, at the time of writing, the criminal trial noted above is still ongoing. Thus, the accused have not been convicted of a criminal offence in this matter. 

Jeffrey Baldwin: A thematic analysis of media coverage and implications for social work practice

ABSTRACT

Jeffery Baldwin died in 2002 in the care of his maternal grandparents. The case received intense media attention at various times over an almost eight-year period. Along with other public documents, the media coverage permits an analysis of the practice errors by Child Protection Services that are related to the failure to protect Jeffrey. Nine key themes emerged around core child protection practices: opening a file; the role of prior knowledge; issues related to assessment; knowing the child and their needs; the role of culture; case supervision; the child as the client; the enmeshment of child abuse; and the role of stability and healing. This analysis offers key lessons to be learned from such cases.

This article has been published in Child Care in Practice

Child protection as racist and poverty driven

It is perhaps somewhat odd that two Canadian newspapers would chose to write articles on the child protection system in the same week.  Looking at several inquiries, The National Post calls for reform of the system They start by noting that there will be an inquiry starting in Ontario in early 2015 on the death of Katelyn Sampson. She was murdered in 2008. The Toronto Star noted:

When Irving told the Children’s Aid Society on March 30, 2008, that she did not think she could provide for Katelynn and wanted her out of her home, the agency “passed the buck” to the Native Child and Family Services — Irving is part First Nations — and nothing was done, McMahon stated. (When a Native Services caseworker contacted Irving 16 days later, she lied and indicated the Toronto School Board was providing support and that she wanted the file closed, which it was.)

This inquiry will add to the long list of inquiries into the failures of child protection in Canada. In my research, we have identified about 80 inquires of various natures with at least two more on the horizon.
These will add to the legacies of Matthew Vaudreuil, Phoenix Sinclair, Christian Lee, Babby Annie, Jordan Heikamp, Kim Anne Poppen, Jeffrey Baldwin and so on. The stories are children of poverty but also of the First Nations of Canada. In other words, these are stories of the marginalized in our country.

The Toronto Star is also running a series of stories into the child protection system. They see the racism looking at how Black children are severely over represented.

Last week, the Globe and Mail told the story of Eddie Snowshoe who died through the solitary confinement system that Canada runs. But hist story starts much earlier in the institutional abuse of Canada's First Nations peoples through the residential school system. There, children were systemically abused and neglected. Today, we pay for that with the long standing impact of such broad, racist based social policies. They were designed to take the Indian out of the Indian. Now, we see the impact of fragmented Aboriginal communities and families in  the child protection systems.

It is obvious that child welfare must do a better job of the day to day management of complex cases. There are practice errors that get made and need to be corrected. That is the subject of my research. But society must also be willing to face the fact that there are several issues child protection cannot solve:

• Poverty - which is too often linked to neglect - not intentional neglect but neglect from lack of resources. These are often families where parents struggle with marginal housing and limited income, most often from low wage employment. They try to do their best with what they have but that often falls short of what is needed. Society can address these issues through economic programs.
• Aboriginal child welfare - the gross over representation of First Nations children in child protection care occurs because of the Residential Schools and the legacy they created. Child Welfare cannot fix that. 
• Underfunded mental health programs that leave families vulnerable.

The list can go on but the point here is that child welfare is being asked to "fix" problems that arise from social policies that are well beyond their control. This is a conversation we must have rather than just pointing fingers at a child protection system that cannot fix it!

Is the Canadian child protection system broken?

Albertans might well be wondering if the child protection systems in Canada are falling apart. Well they might. In December the Calgary Herald / Edmonton Journal ran a series of articles detailing concerns arising from the deaths of children in care. This was followed by Alberta Human Services Minister Bhullar announcing even more deaths.  Recently Justice Ted Hughes’ report into the death of Phoenix Sinclair in Manitoba was released. He determined the death was preventable by the very system that should have saved her. This past week, the Coroner's Jury made 103 recommendations to arising from the death of Jeffrey Baldwin in Toronto a decade ago.

Jeffrey Baldwin

Canada has had over 50 public inquiries into children who have been killed or harmed while child protection has been involved in their lives. Each report has detailed errors made by social workers. Each has left readers shaking their heads that professionals could have done such a bad job. The reports, of course, only focus on the “big” cases where things have gone badly wrong. Truly, these are stories that deserve to be told. They should not be hidden from the public as no system can sustain any level of confidence when it is not open to scrutiny. Such reviews though should highlight what goes well and what does not. The stories of the successes also need to be told such as the three young women at the Minister Bhullar’s roundtable on child protection who have spent significant parts of their lives in the care of child welfare. These young adults who are taking steps to transition into adulthood showed their individual strength overcoming adversity. They had the support of an effective child protection system.

Child protection is hard work. Imagine showing up at a family’s home, knocking on the door and announcing that you are there to investigate an allegation of abuse or neglect. You cross a boundary. We view the family unit as a basic of society that should largely be left alone to get on with the task of being a family. Child protection steps into that world with the force of law. The social workers will need to determine if the child is safe and, if not, what needs to be done to ensure that child’s safety. Sometimes, that means removing the child from parental care for a temporary period. In a small but profound number of cases, that may lead to the permanent removal of the child. Even when parents have acted quite dangerously towards their children, these removals are almost always traumatic for both parents and children. There is a delicate balance between sustaining the family unit and achieving safety.

There are checks and balances. A child protection worker removing a child is subject to the scrutiny of the courts. For the parent who has lost their child, that can be little solace as they wander down the hall and stare at the empty bed that only a few hours ago was occupied by their child.

Imagine, however, if there were no child protection system. There would be more children dying at the hands of caregivers. Simply put, there would be more stories like Phoenix Sinclair. That is not a world that appeals to me. A child protection system that is not subject to review is equally unappetizing as there can be no belief except by faith that they are getting it right. Courts are one way that scrutiny happens. As the roundtable noted, there needs to be more transparency. The public should be able to get data that tells them how the system is doing.

Phoenix Sinclair

Yet, there is no child protection system that can guarantee that another child will not be seriously harmed or killed by a caregiver. This is very human work in which social workers must make decisions with highly imperfect information. There are no tools, nor will there ever be, that can come even close to absolutely predicting the risk that a parent presents. There is only probability. To expect that social workers can prevent all deaths of children by parents is to expect the impossible.

Child protection also cannot solve poverty, unemployment and lack of appropriate resources across this country. Yet, child protection is asked to pick up the pieces of these social problems. Thousands of children would not be in care if these problems were better addressed.

If we want better child protection services, fund them appropriately so that case loads are manageable, prevention and healing work is achievable and bring in social programs that will help to reduce the need for child protection across Canada. This also means that the federal government must start funding First Nations child welfare programs at the same rates that provincial programs are funded. Why should an Aboriginal child on a reserve receive less funding than a child under provincial authority?

The system is not broken, but it is certainly imperfect. Thus it must be transparent. The Calgary Herald and Edmonton Journal took four years to get the records on child deaths. That is just wrong and erodes public confidence.

Kaenu Williams and Marchella Pierce - some common territory in their tragic deaths

By chance, the Serious Case Review (SCR) into the death of Keanu Williams in Birmingham, UK and the grand jury deliberations regarding the death of Marchella Pierce in Brooklyn, NY were published in the same week. Also by chance, are some common themes. For any of us connected to the world of child protection, both reports are disturbing not only in their details but also in the familiarity of the concerns that they raise.

Injuries to Keanu Williams

The injuries to Keanu were extensive as the above illustration shows. The mother had prior history with child welfare as a child in need as well as with her other children. Prior history is something that is seen in many cases, although certainly not all. But the all too familiar aspects of the case were, as the SCR notes "...various agencies involved had collectively failed to prevent Keanu's death as they missed a significant number of opportunities to intervene and take action" (p.6).  The SCR concludes that the death could not have been predicted.  This is a point that many media have noted. But, also on p. 6, the SCR goes on to state,

However, in view of the background history of Rebecca Shuttleworth and the older Siblings including the lifestyle and parenting capacity of Rebecca Shuttleworth and the vulnerability of Keanu in Rebecca Shuttleworth’s care; it could have been predicted that Keanu was likely to suffer significant harm and should have been subject of a Child Protection Plan on at least two occasions to address issues of neglect and physical harm.

In other words, had the various agencies and authorities been paying attention, communicating with each other and giving priority to the child, the outcome may well have been different. As the SCR notes on p. 8, there had been a lack of focus on the children of this mother. The SCR found themes that have been repeated often in these kinds of reviews:

A number of the issues which have arisen in this Review are also familiar themes in Serious Case Reviews nationally, such as: poor communications between and within agencies, a lack of analysis of information as well as a lack of professional curiosity in questioning the information, a lack of confidence among professionals in challenging parents and other professionals, short comings in recording systems and practice, professional over optimism rather than to ‘respectfully disbelieve’ and dealing with events as one off episodes often referred to as the ‘start again syndrome’.

The start again syndrome is dangerous. There is no other way to put it. It is a way to ignore history. Something that a child protection agency does at its peril. In Canada, we are experiencing the brutal inquest into the death of Jeffery Baldwin where the child protection authorities failed to read their own files to see that the grandmother who starved Jeffery to death had been previously convicted of child abuse.

As the Keanu Williams SCR notes, it is the business of child protection to stay focused on the child's journey. But to do so requires the time to be so focused. This brings us to the Marchella Pierce case where the former case worker and the case work supervisor are both facing charges in her death.

Amongst other things, the Brooklyn Grand Jury notes that the workers faced a system that had failed before. But, case loads are high. Problems have been identified and not corrected. Now, rather than the system being held accountable, there is a risk that the people working in the system will be the scapegoats. We have seen that before as well with the Baby Peter case in the UK where Sharon Shoesmith was vilified in the media.

Marchella Pierce

Workers faced with high caseloads will make mistakes and the clients, children and their families will suffer as a result. Should we hold the caseworkers liable or should we be having a discussion about whether or not society should be held accountable by failing to fund child protection at a rate needed? Or by not funding the kind of prevention services needed?

There is also the ugly truth that, no matter what we do, some parents will kill their children.

In my research, I have catalogued about 900 cases where children have died when child protection was involved. I have missed many cases I am sure, Each week, I add to the list. But each week I see a repetition of the systemic issues such as these.There is no easy solution. We need to continue to highlight these cases putting pressure on governments to properly fund both prevention and reaction services.

Child protection's inconvenient truth: Is Daniel Pelka an example?

Media in the United Kingdom are swarming around the death of Daniel Pelka. He was four years old at his death at the hands of his mother, Magdelena Liczak and step father, Mariusz Krezolek, . They have now been convicted of his murder. He was starved and treated cruelly for at least 6 months prior to dying.

Daniel Pelka

The media reports are slowly leaking into Canada, although they are not creating the sensation that even a casual reading of UK papers suggests is going on there.

There is a serious case review in the matter, but its publication has been delayed until next month. Apparently the SCR panel learned information in the trial that it must now consider. That, in itself, is a fascinating statement suggesting that those working on the case had information gaps. At this point, it is not clear the child protection had a significant, or even any role in the family. The case is, none the less, highly reminiscent of many cases such as Jeffrey Baldwin, Victoria Climbie, Khyra Ishaq, Logan Marr and so on. Here in Canada, we have another tragic case subject to a public review that has just finished up. This is the case of Phoenix Sinclair. It will be several months before we hear what the commissioner, Justice Ted Hughes has to say.

In all of these cases there are valuable lessons to be had on child protection practice. These cases highlight the ways in which case management and interventions can go wrong. They also help us to see the sorts of common errors that occur. It is those errors, in particular, that need avoidance.

Cases such as these raise the delicate balance between protecting children and preserving families. The challenge with these cases is that they inevitably result in several things:

1. A scapegoat will be sought. In Daniel's case, the politicians are already doing this;
2. In some fashion, a politician will also state that the protection of children is paramount and that they intend to get to the bottom of this so it will not happen again;
3. New procedures will be introduced, manualized and bureaucratized; 
4. New training will be recommended; 
5. Social workers will become wary and fearful of making a mistake; and
6. Another child will die.

I am reminded of the article by anthropologist  China Scherz in the United States who looked at how social workers try to put into place good judgement while also trying to manage that balance between protection and family. She looked at the introduction of actuarial tools to help better identify risk. Her article is well worth reading. What one concludes is that there is a real risk that we create what looks to be science (e.g. actuarial tools, structured decision making processes, formal assessment processes) which mask the reality of child protection in science. It is a false mask.

While I am a supporter of these various types of tools, there is still the reality that a front line worker is going to have to make decisions from that information - leave the child in the home? close the file? remove the child? offer services? Scherz's article shows that this still is a very individual decision that a worker must make, and that there can be a wide variance in the ways that workers see a case.

There is no way to remove the worker and the personal decision making from the work. Workers bring training, experience and, yes, beliefs into the day to day interaction with families. No matter how much structure and science you try to wrap around that, this truth remains.

Which leads to the inconvenient truth in child protection - mistakes will be made, children will be subject to further abuse and maltreatment that might have been avoided if a different decision was made, and a small number of children involved in child protection will die - but most will not.

To expect perfection in child protection is unrealistic. Let these tragic cases continue to serve as educational opportunities so that the common mistakes can be highlighted and the highly unusual errors can also be brought to light.

Reference:

Scherz, C. (2011). Protecting children, preserving families: Moral conflict and actuarial science in a problem of contemporary governance. PoLAR: Political and Legal Anthropology Review, 34 (1), 33-50.