Investigation in British Columbia may be asking the wrong questions

The Royal Canadian Mounted Police (RCMP) announced in B.C. what has been hailed as a groundbreaking investigation. They will look into the actions of care workers who were involved with a First Nations youth, Paige, who died as a young adult from a drug overdose. Paige's case was the subject of a scathing report by the B.C. Representative for Children and Youth, Mary-Ellen Turpel-Lafond.

Paige as an infant, child and youth

In that report, social workers are noted to have failed to properly assess her needs; failed to communicate between regions as she moved around the province; didn't persist in trying to work with her as she became more challenging to engage; allowed her to live in some of the most dangerous, drug addicted areas of the province and often saw her without arranging further contact with child protection authorities. She died at the age of 19. She had many problems including Marfan syndrome which left her with very challenging eyesight, medication and cardiac health issues along with her addiction, trauma history and likely mental health issues.

As the CBC reported on September 18, 2015, "Paige as taken to hospital or detox at lest 17 times after being found unconscious or incoherent; she changed schools 16 times; and she featured in more than 40 police files, mostly for public intoxication." Yet, these incidents generally did not result in filing a report to child protection in accordance with provincial legislation. Like most Canadian provincial child welfare legislation, B.C. requires professionals to contact child protection whenever they suspect that a child is in need of protection.

It is the failure of authorities to make these reports that is the subject of the police investigation. But are they asking the right questions? It's tempting to be satisfied that the police may hold these workers accountable for their failures. That may make many professionals more aware although that might also lead to flooding the system with reports and more children coming into care. There can be a "fear chill" arising from such police efforts.

Despite the merits of a police investigation, it may be that the wrong questions are indeed getting asked. I find myself wondering (as I have with virtually all of the over 900 child welfare practice reviews I have read) what structural conditions lead to these kinds of failures.

• What causes professionals to believe that a report should not be done?
• What allows workers to believe that hard to reach youth are so challenging that you let them be in dangerous situations?
• What circumstances lead workers to fail to gather data from others who have worked with a youth?
• What did professionals believe would make a call to child welfare not worth doing?
• What is that professionals did not understand about their duty to report or has past experience caused them to believe that such calls are not worth doing because they cannot see any changes occurring?
• What kinds of supervision exists to support these decisions?

Yes, it is worth asking why these workers did not do what should be done but the questions are much broader. There has never been a prosecution under this section of the B.C. legislation. Turpel-Lafond hopes that this will be a turning point. I fear it may not be the one she wants. How many professionals will now decide that working with child protection cases should be avoided, for example.

Paige is a distressing story

The story of how a British Columbia First Nations girl was let down by child protection authorities has been documented in a report by the province's Representative for Children and Youth. It is a hard read. Page after page, you are left wondering how social workers decided to make the decisions they did - leaving this vulnerable child in care situations that were clearly risky; believing that interventions would work when there was little evidence that they would; failing to see the child. As the report notes on p.5, "Professional standards of care were not upheld in how Paige was treated."

This is a child who was subject to maltreatment throughout her life - from infancy to early adulthood when she would die. In some ways, looking back, you can see that she was destined to die early given the amount of maltreatment in her life. She experienced a number of adverse life experiences (ACEs). The ACE research project shows convincingly, that people who experience three or more of these events, have a dramatically higher rate of illness, addiction, mental illness and early death. Based on what is written in the report, her score may have well been in the range of 6.

It didn't have to be that way. Early intervention could have made a difference in terms of both the quality of her life and its duration. She need not have ended up in the Downtown Eastside of Vancouver - one of the most social disadvantaged communities in Canada.

Having researched hundreds of reports like Paige, I am struck by the similarities of repeating problems including (but certainly not limited to):

• being too optimistic that change will occur thus minimizing or not seeing the ongoing and growing risk factors;
• failing to see that repeated efforts at change are not making a difference;
• not putting the needs of the child as the most significant priority;
• failing to coordinate information available from a variety of sources;
• failing to look for the permanent solution believing that being with biological parents was somehow preferable; 
• creating instability through multiple moves and placements;
• failing to follow up on case plans;
• having poor case supervision;
• not really knowing the file;
• not completing needed risk assessments;
• not understanding the nature of addiction.

The Representative's report states on p. 6:

This is a child who should have been permanently removed from her mother’s care at an early age. She was the subject of no less than 30 child protection reports during her 19 years, involving allegations of domestic violence, neglect and abandonment. Her mother was actively using alcohol and drugs and there were no signs of that behaviour abating. Paige was repeatedly returned to her mother by the Ministry of Children and Family Development (MCFD) despite glaring and unavoidable evidence that this was not a healthy, nurturing or safe environment for any child and wasn’t ever likely to be.

As a result, Paige’s life was a case study in chaos. By the time she was 16, she had moved no less than 40 times, between residences with her mother, foster homes, temporary placements and shelters. After her mother moved them to the DTES in September 2009, Paige lived with her in toxic environments and moved another 50 times, living in various homeless shelters, safe houses, youth detox centres, couch-surfing scenarios, foster homes and a number of Single Room Occupancy (SRO) hotels.

As I noted, I have read quite literally hundreds of these reports from Canada, Australia, the USA, England, Ireland, Scotland --- the themes are painfully consistent. So why is that?

Often we think of systemic problems - poor resourcing, over worked social workers, funding problems, weak supervision of front line managers. These are all true. As a profession, however, we must start to look at the quality of care that we are providing. Ultimately, we are responsible for what we do with a client.

We also need to look at the education social workers receive. How well are we preparing students for the real world challenges of managing cases like Paige? We also need to look at politicians for honest leadership that is backed up with funding, resources and the sense that child protection is a priority as opposed to a service to keep the sad stories in check. Political leadership also recognizes that there are problems which child protection cannot solve - poverty, crime in communities and so on.

As a society, we need to have a longer attention span to these issues. Stories like page hit the headlines, people shake their heads and wonder how such a tragedy could occur, politicians nod and speak of change and then……… nothing. The story fades while the media seeks out the next big tragedy to talk about. The themes are telling about tragedy not about actual real change. When society really pays attention, things might change because then the politicians can expect to be held accountable.

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.