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.

Phoenix Sinclair Report recommendations go over all too familiar ground

The inquiry headed by Justice Ted Hughes into the death of Phoenix Sinclair has now issues its report. It turned out to be the most expensive inquiry in Manitoba's history but it covers territory that is all too familiar. Mistakes by social workers that should never have been made in a system that ought to have prevented the death. This is part of a long line of inquiries that reach very similar conclusions.

The full report can be read here.

Phoenix Sinclair

The report does make some very valuable suggestions such as all child protection workers should be trained social workers who are registered with the Manitoba social work association; case loads be kept manageable; records be well maintained; better communication with others involved including when transferring a case; the system be more transparent and that more effort be put into prevention.

The big idea that Hughes came up with is that child protection requires a national conversation. He suggests that the issue belongs on the agenda of the next Premier's conference which the Manitoba premier has asked be done. The notion of a cross country conversation makes a great deal of sense. I recently attended a roundtable on child protection here in Alberta which was organized by Human Services Minister Manmeet Bhullar. In his opening comments, the Minister noted that there have been over 50 reports on child protection problems across Canada. I have read them. They have a numbing familiarity raising problems about caseloads, funding, the decision making environment, poor communication between agencies, poor record keeping, the need for better training, missing cues and so on.

What so many reports do not address is the very human nature of child protection work. Social workers are rarely invited into families. Most often, they arrive because there has been an allegation of abuse or neglect which requires investigation. Families are very understandably defensive and sometimes downright resistant. This is so much an issue that last year Siobhan Laird wrote a text on managing conflict, hostility and aggression in child protection. It is in that environment that a worker must try to determine the safety and risks for a child.

The information is always (and I use that word very consciously) incomplete. No social worker ever knows everything that is relevant. Thus, the decision making is done with an information set that is changing constantly. Decisions often need to be revisited. There is no way (again I use that phrase consciously) that a worker can predict with absolute certainty the risks. There is probability. We are still faced with the fact that the best predictor of future behaviour is past behaviour in the absence of a compelling story of change.

Part of the challenge with child protection is that there is an expectation of perfection. There is a zero tolerance in the public's mind regarding a death of a children. But there is a reality that no system anywhere can guarantee that. We do have an obligation to provide the best system we can and to really understand how we can reduce risks.

There is also an obligation by society at large to fund prevention which is best done by poverty reduction. The majority of children brought to child protection attention are related to neglect - which is very strongly rooted in poverty. Reducing poverty reduces children in care which increases the attention that can be paid to the higher risk cases.

Assessing risk in child protection - but what risk?

When one thinks of assessing risk in child protection, one might automatically think about risk to a child. Is the child safe? If not, what needs to be done? Should the child be left with parents or removed? If there are immediate risks, can they be mitigated. These are all important risk questions.

However, there are two other facets of risk that are often not spoken about but can play very crucial roles in assessing risk in a family - risk to the social worker and risk to the agency. Both of these risks are by products of the outrage that occurs when a child is seriously harmed or killed while child protection is involved. There have been a myriad of high profile cases in Canada, Australia, New Zealand, the UK, Ireland, the United States and elsewhere. Here in Canada, we are awaiting the release of the Hughes Inquiry into the death of Phoenix Sinclair. It is expected to be released early in 2014. Based on prior inquiries that Justice Hughes has done in other provinces, one can expect a thorough report that will make for grim reading. It is these types of reports that are needed but also create a fear response - who wants to have the next high profile case in the media after all.

Phoenix Sinclair

For the social worker, this means that each case decision is also influenced by the risk to the social worker. What is likely to happen if this decision turns out to be riskier and problems occur? When this pressure exists within the decision making process, then there develops a tendency at self protection. This leads to more conservative decision making where getting more intrusive with a family seems like the best path.

So too for the agency or the team managers who do not want to be the next team under public scrutiny. 

Thus, the decisions around what a child needs are influenced by matters that have really nothing to do with the risks to the child.

Some attempts have been made to influence this decision making process by introducing programs such as Signs of Safety. This looks to a family's strengths that can be utilized and enhanced. The goal is to reduce the number of children living away from home. It does require that the agency take more risks that enhancement can occur. The early research tends to be promising. But it does require that the agency be able to tolerate the higher risks. Even more important, is for the politicians to be able to accept the risks.

When things go wrong, politicians have zero tolerance for errors even though errors under any program are inevitable. Child protection decision making is done in a reality of partial information that is almost constantly changing. It is politically difficult to defend the imperfections of decision making when the public is outraged.

There are also factors that child protection cannot solve particularly poverty, crime in neighbourhoods, family breakdowns and unemployment - even those increase risks. Politicians can create social policies that do reduce those risks - but cannot eliminate them.

Thus, while we want social workers to be the best they can at the work they do, no matter how well budgets are managed and case loads are kept low, there will still be errors and fatalities - albeit fewer. This is a very hard argument to sell as a politician but it is reality.

Readers might also find this comparative work between the UK and Belgium of interest

Also of interest will be this blog from Chris Mills in the UK.

Phoenix Sinclair Inquiry

The inquiry into the death of Phoenix Sinclair is starting to open up some distressingly familiar themes in the world of social work.

What we are beginning to hear about include high caseloads, demanding work schedules, frequent turnover of staff, a child not seen, a case that appears to have relied heavily on self report by the family and social workers who didn't build enough of a relationship with the family to really know what was occurring. For many of the social workers who have testified at the inquiry, this case was not so severe when compared to others they were trying to manage.

For Justice Ted Hughes, an experienced commissioner in child protection inquiries, the task in front of him will be to look beyond the obvious concerns - social workers who didn't get the job done - to the very broad issue of the systemic issues that made it impossible to do the work needed to protect this vulnerable child ---- and many others like her.

Justice Hughes will need to think about the poverty; the intergenerational problems in Canada's Aboriginal Communities (strongly linked to the story of Residential Schools in Canada) and the failure to properly fund child protection. The Phoenix Sinclair case can too easily be framed as a failure of individual social workers. That is easy. They become the convenient scapegoat. Hughes should look at how we fund child protection; how we fund prevention services; how we address real healing and - most of all - whether we in Canada want an effective child protection system or do we want the feel good of having one but not spending too much on it. It is a deep moral question.

I fear that Canada, like many Western countries, are not prepared to pay what real child protection and prevention would cost.

Phoenix Sinclair Inquiry

While there is much evidence yet to come in the Manitoba Inquiry into the death of Phoenix Sinclair, one piece of it that emerged last week has an all too familiar ring to it. It is one that we have heard in so many of these inquiries in various countries - case loads that were too high. In this case, the social worker who was testifying spoke of initially having 40 cases to manage - an impossible number.

However, the worker goes on to explain that more than the case number, is the number of children being managed. She described that you could cut the caseload in half but still face over whelming demands with families that have high numbers of children.

Maybe it is not the number of cases that should be considered but the number of children that should be the gauge of what is too many.

Yet two fundamental problems would persist - 1. not enough social workers are being drawn into child protection work and 2. retaining those that are is challenging with high caseloads, complex needs and limited resources with which to work.

One hopes that as Justice Hughes works his way through this inquiry that he will look at some of the core issues facing child protection and social work. There will be more to think about as the evidence unfolds.

Justice Hughes has ruled on the Phoenix Sinclair Inquiry

Justice Ted Hughes has now ruled that the public inquiry should be fully public indeed. This means that all witnesses, including social workers, will have their testimony publicly available.  A good summary of his lengthy ruling is offered by The Winnipeg Free Press

Should social workers at the Phoenix Sinclair Inquiry have anonymity

Justice Ted Hughes has been asked to conduct a public inquiry into the death of Phoenix Sinclair. She died in 2005 when social workers took her out of her foster home and placed her back with her mother. According to  Canada.com:

According to evidence in the first-degree murder trial that led to life sentences for her mother, Samantha Kematch and her stepdad, Karl McKay, Phoenix was frequently confined, shot with a BB gun and forced to eat her own vomit. 

We have seen how social workers who appear to have made mistakes in a child protection case can be vilified in the media. Those involved in the management of the Baby Peter case in England were dragged through the press and scapegoated and judged harshly by the media.

In the case of the Matthew Vaudreuil case in British Columbia, social workers felt targeted by the Gove Inquiry. Some may have suffered for years from the experience.

Too bad critics might say. They might argue that if you fail in your job, then the public has the right to know. Yet, social workers are often trying to manage case loads that are too high; cases that are very complex; resources and budgets that are limited and political agendas that children should be reunited with family as often as possible (the family preservation agenda).  A child kept away from family unnecessarily is a tragedy - a child returned and killed is one also.

RCMP officers in the Robert Dziekanski case in Vancouver (when he was killed by a Taser incident) were not granted anonymity before they were found culpable.

The majority of professionals who make mistakes in their work are not dragged into the media. Public inquiries might be a different kettle of fish because government has purposely set up a process for the public to find out what went wrong.

There are many examples of public inquiries where the names of social workers have been made public and many where they have not. The argument in favour is that the public have the right to know - but do they need to know the who? What perhaps they really have the right to know is what happened.

The goal of a good inquiry is not retribution. Rather it is an attempt to find ways to avoid repetition. Good inquiry seeks to understand but to get there, participants need the freedom to really talk about what happened and why. If the participants fear the consequences, then open discussion is unlikely . Rather, protection of self becomes the goal.

Justice Hughes must decided how best the truth will come out.