Handle with Care
Twenty years. Hundreds of deaths. In our exclusive six-part series, Leader-Post reporter Barb Pacholik examines Saskatchewan’s child welfare system.
TODAY
Part 1: In the past two decades, more than 500 children have died while in care or within 12 months of receiving services from Social Services. For the next week, we’ll look at the numbers, why and how children die in care, and some of the faces behind the statistics.
MONDAY
Part 2: In 1983, a 22-monthold Regina boy died in a Regina foster home. That death became a call to action for activist Brenda Dubois, who has spent three decades fighting for children like Christopher.
She was a mere 20 months old, a toddler found cold and lifeless in her playpen in an overwhelmed foster home.
Within months of her apprehension by Social Services, Karen Rose Quill’s life ended — one of roughly 500 children and youth who have died in Saskatchewan’s complex and overburdened child welfare system in the past two decades. A quarter of the kids were in Social Services’ care when they died, the remainder in receipt of its services within the year prior. According to overall numbers from Social Services, about 40 per cent of those young lives ended by natural causes, but an equal number were preventable deaths, victims of homicide or accidents, like Karen.
“Children, particularly very young children, have no direct voice in the child welfare system,” wrote the province’s first Children’s Advocate in her report on Karen. “These children have no voice to demand a higher quality of care.”
Karen died in 1997, two months after she was placed in a St. Louis foster home approved for no more than two foster children, but already at six: A nineyear-old, a four-year-old, three three-year-olds, and another child under age two. They were in the care of a single mom, who told workers she was struggling. Karen was the lone girl among a group the foster mom found difficult to manage. In her 109 days in care, social workers never visited Karen’s foster homes. In fact, no worker ever visited any of the seven foster children in the St. Louis home in the two months Karen was there.
But Karen’s mom visited, and she was concerned by the lice and cuts she saw on Karen and her brother. She asked that they be moved — to no avail. A week later, on Sept. 13, 1997, Karen was dead, having somehow suffered numerous blunt injuries, likely inflicted by the other unsupervised children.
She died from internal bleeding and an injured liver.
Karen was ground zero for the Children’s Advocate’s Office, its first comprehensive review of a death in care. It was also the first scathing report to condemn overcrowding and overwhelming foster parents, but not the last.
Why dwell on a death from nearly 20 years ago? Because despite the best of intentions, more deaths followed — roughly two a month, on average — and at times exposing similar gaps in child protection. It’s not that there aren’t also child welfare successes. But as the grandmother of a threeyear-old Regina boy said after an inquest revealed he had died of a treatable chest infection in foster home rivalling some hoarders’ houses: “One dies so many will live.” Only by exposing the failures can others hopefully be spared.
In some cases, children apprehended for fear of suffering neglect or harm have died of exactly that — in foster homes, at the hands of unfit surrogate caregivers or even inflicted by their own parents when returned home by social workers.
Why are children dying in system that aims to care and protect? What has been and is being done? Those are some of the questions the Leader-Post explores in its six-part series Handle With Care, continuing next week.
The comprehensive numbers don’t appear in any Social Services report, but were compiled in response to our request. Adding up to 525 young lives lost while in care or in receipt of services, they are stark — but also frustratingly imprecise before 2007 (see sidebar). The ministry began its Child Death Review policy in 1992, but who was included varied. In a quest for more accuracy, the Children’s Advocate Office — which also began to review those child deaths when it was created five years later — spent this week reviewing every one of its files. And its total is also grim at 424 deaths. Coupled with the first five years of Social Services statistics, the total comes to 539.
“Any child that dies in care or in receipt of our services is a tragedy,” says Natalie Huber, executive director in Child and Family Services. She says the ministry’s focus is on the circumstances of each individual death — to ensure a high standard of care — rather than dwelling on numbers.
Asked how they might compare to child deaths generally in the province, Social Services stated: “While we have periodically reviewed the statistics of child deaths in the general population these numbers have little to no correlation with our MSS Child Death related statistics.” So the Leader-Post did its own calculations using Statistics Canada data on Saskatchewan’s population and deaths of those aged 0 to 19 between 2007 and 2011 inclusive and found the fiveyear average rate was 0.7 deaths per 1,000 people. Using Social Services numbers strictly for kids in care for those same years, the average death rate was 1.5 per 1,000 people.
The details of most deaths are never known because of a veil of confidentiality laws. When made public, reviews cite overwhelmed caregivers and workers, miscommunication, misjudgment, poor oversight, inadequate checks, and human error.
“I just want them to say it’s their fault,” says Chris Martell, the father of Evander Daniels. A trial last year revealed the tragic story of the toddler’s death at 22 months old in an overburdened foster home, like Karen a decade earlier.
Other children that followed Karen to the grave include: A two-month-old girl who suffocated after falling from a bed into a garbage can in an overcapacity, single-parent foster home; a 10-week old who was beaten to death by her father, a drug addict on bail with a violent record but deemed a fit caregiver by a social worker; and a 17-month-old, born to a drug addict, who died of a common skin infection despite a social worker’s involvement.
A Regina death two years ago sparked a lawsuit against the province and manslaughter charges, still outstanding, against two caregivers. June Goforth, 4, died in the care of “a person of sufficient interest” or PSI, an increasingly popular alternative to foster care but without equal scrutiny.
“That’s the next crisis area if it isn’t managed properly,” says Children’s Advocate Bob Pringle.
Each death or critical injury prompts a comprehensive review by the ministry’s quality assurance unit, a specially-trained team of former child protection workers. A review usually takes three to six months but may be accelerated if a problem is identified “so we can make any adjustments,” says Huber.
Almost 44 per cent of the children who died in care were “medically fragile,” with pre-existing conditions. “We’re of course dealing with some families that are very vulnerable,” says Huber. Asked if a higher level of care or more special training in child welfare are needed, Huber says they are provided.
As for the high number of accidents, Huber says circumstances vary. According to the Advocate, accidents have included everything from drug overdoses and collisions to unsafe sleeping arrangements.
“The ones where you might see that there could have been a different outcome are of course very concerning,” says Huber. Death reviews inform future programs, policies, training and changes that have contributed to better care, she adds.
Although the reviews are not publicly released, Huber says there is public accountability through the Advocate’s review, which may release some details.
“We try to take every measure possible to ensure that we are providing safe and accountable services,” says Huber. “But ... there are some of those circumstances as well that are clearly beyond anyone’s control, with pre-existing medical conditions or circumstances that just do occur.”
Circumstances that do occur — like an overwhelmed foster home or an unfit caregiver — but shouldn’t.