"Mom Dead, Mom Sleeping": Systemic Failure Hurts Children & Erodes their Human Rights

“This child led a life that was impoverished in every sense of the word”
- Mary-Ellen Turpel-Lafond - Representative for Children & Youth

Systemic neglect simply does not get worse than what happened to the 15 year old girl with Downs Syndrome who was left with her, impoverished mother, who died, while this vulnerable, completely dependent young woman was left with her mother's dead body for over a week.

The title of this blog post are the only words and voice this girl was able to have in all of this. This blog post is dedicated to her and to her brothers, who tried to get her help and were ignored and to their mother, whose life was filled with so much pain and isolation. No-one should ever have to bear so many challenges alone.

BC's Representative for Children & Youth has released a special report on this situation, entitled, Isolated and Invisible: When children with special needs are seen but not seen examining the child and family involvement with MCFD and how such a tragedy could happen in BC.

This is a heartbreaking case on so many levels it is staggering for any reasonable citizen to consider the harm created by the failures of so many systems. Here is a breakdown of systemic failures contained in the life of just this one child.

One brother reported his concerns about his mothers abilities to care for his sister to MCFD, asking them to intervene. Although ill prepared to deal with his sister's special needs, the brave young man tried to intervene on behalf of his sister, because they knew firsthand the kind of risk she was at. He was told he must return his sister to their mother, whose drug and health issues were well established, or he would face complaints of kidnapping. Systemic failure.

The community that is so broken down that a sick mother and a fragile special needs girl were not seen, or missed by anyone for over a week. Many days passed and no-one looked into the trailer to see this beautiful and caring girl trying to tend to and curled up with her mother's dead and decomposing body. Lovingly trying to bring her food and medications, to revive her mother, while her own physical condition deteriorated through malnutrition, dehydration and sitting in a soiled and wet diaper for days. The emotional trauma and harm and inability to make any meaningful sense of what happened will live with this girl forever. No meaningful sense could ever be made for this situation in a so-called civil society. Systemic failure.

The child protection system, in spite of attempts to investigate, simply did not care enough to act to protect this child because it is more concerned with keeping the numbers of children in care down. The two brothers grew up with their mother. They likely bear the scars of a childhood left to a parent with minimal capacity to meet their needs due to her own problems and issues, which could likely be found in her own childhood experiences. This is the cycle that the child protection system in BC does little to break and often contributes to by leaving children at-risk throughout their childhood, the only one they will have. The paradigm has swung back and forth and in spite of reviews, children dying and being permanently harmed, childrens rights to safety and protection still takes a back seat to parents rights and even the child protection system will seek to protect itself over children rights. Systemic failure.

One of the hardest lessons I learned working in child protection and I learned it quickly, is that love is not all children need from parents. I've never worked with a parent that did not love their child. I have worked with many parents that, mostly through no "fault" of their own, simply did not have the capacity to be a minimally adequate parent. It may surprise most people that the bar is set so very low for children - the standard is "good enough." But there is no definition beyond this. Situations like this demonstrate that the bar is set unconscionably low for children in the child protection system in BC in 21st century.

I happen to believe children deserve a much, much higher standard and that it is the obligation and duty of our province and our country to provide that in a civil society.

The welfare ministry's heartless policy of cutting people off who have not been heard from is an example of the impacts of service re-design in which individuals no longer belong to a single caseload. Human beings have simply become a number on the welfare rolls, a number to be cut if possible. I suspect this mother had been on income assistance, or disability for many years, yet when she was not in contact with her local office, this did not get flagged as unusual, although their records would also have indicated there was a minor child in the home. That system took no steps to report any concerns to MCFD, CLBC or law enforcement for follow up. Systemic failure.

The school that this girl attended, beyond making phone calls, did not apparently take any action when she did not show up for school, likely because her absences became normalized, due to the inability of her mother to consistently get her to school. This was a red flag that was ignored and MCFD should have been called. Systemic failure.

As the report details, after the girl was found, her former respite worker was called to come pick her up. MCFD did not even provide adequate resources to the child then. The child was not admitted to hospital and was still wearing her filthy clothing when this kind soul picked her up. She purchased necessities for this traumatized and wounded girl out of her own pocket because MCFD did not provide her with one dime to meet the immediate needs of this child. Systemic contempt and failure.

This latest report from the Representative articulates what many who work with young people with special needs have known for many, many years - people with disabilities are rendered invisible and are isolated, while living surrounded by community and the wealth of this province and its well paid Ministers, bureaucrats and elected officials. People with disabilities are shut in and shut out of meaningful participation in society, marginalized and socially excluded. Systemic failure.

The CYSN social worker said she had a caseload of more than 200 families when the
transfer of special needs services from CLBC to the ministry occurred in October 2009. This is a little known secret to the world outside of Community Living, workers case loads are in the hundreds by design and for the economic benefit of government to keep costs down. Systemic failure.

My colleagues working in with Children with Special Needs in care and living with their families and parents have been raising alarms for some time now about the lack of social inclusion and participation facing individuals with disabilities once they age out of education programs. Their lives and opportunities to engage in meaningful learning and social connection become diminished with few programs available once they reach adulthood. Systemic failure.

As the Representative writes:

All children with special needs must be given full opportunities to live fulfilling and rich lives. They must also be afforded their right to have equal access to the same programs, supports, opportunities and hopeful futures as others.

So often with cases that go wrong, MCFD shifted into COA mode (Cover Our Ass). As this case and so many others over the years have demonstrated, MCFD becomes more concerned with limiting its organizational liability than learning from mistakes and creating policy and practice that will prevent tragedies like this from ever happening again. One of the ways MCFD does this is by failing to conduct internal investigations and reviews of cases where children known to MCFD are critically injured, or died. Elements of this internal focus of protection can also be seen in the MCFD response to formal complaint the brother filed, which concluded all that could be done, had been done. Something any lay person can see is not true at all.

Under the leadership (and I use that term lightly) of the previous Deputy Minister, not only did MCFD not review this case, they did not report it to the Representatives office, which resulted in a very public and unacceptable wrangling with the Representatives office so that they could do the job for which they have statutory duty - to monitor and report out on the safety and well-being of children. Systemic contempt and failure.

This case also demonstrates the terrible and irresponsible practice of MCFD of opening and closing files, rather than keeping files open for long-term support and monitoring. The mother lacked follow through and compliance with recommended services and this deserved continuing attention and escalation of the child protection response from least intrusive supportive measures.

One thing I also learned working in child protection is that sometimes rather than come right out and tell the authorities they cannot cope with their parenting obligations, sometimes parents would rather send passive messages of inability to cope and that is usually through a lack of follow through, thus forcing an attentive MCFD worker to increase the response. The signs were there, people made reports to MCFD and there were numerous grounds by which this child should have been removed from her mothers custody and placed into care. This did not happen to the profound harm of this girl, who deserved so much more.

When protection is needed

13 (1) A child needs protection in the following circumstances:

(a) if the child has been, or is likely to be, physically harmed by the child's parent;

(d) if the child has been, or is likely to be, physically harmed because of neglect by the child's parent;

(e) if the child is emotionally harmed by the parent's conduct;

(f) if the child is deprived of necessary health care;

(g) if the child's development is likely to be seriously impaired by a treatable condition and the child's parent refuses to provide or consent to treatment;

(h) if the child's parent is unable or unwilling to care for the child and has not made adequate provision for the child's care;

Key Recommendations

• Focus on the needs and best interests of the child are paramount, not the parent, or system. This is even more crucial for children who experienced complex health, behavioural and emotional challenges.
• Appropriate use of the Family Development Response and ensure follow through on the part of parents who are referred to support services as a least disruptive response to child protection reports.
• Collaborative, multi-disciplinary involvement and information is crucial to assess real risks to children and their safety and well-being. Collaterals with any and all parties involved with a child and family are imperative actions that must be taken in assessing risk of future harm.
• Decrease unreasonably high and overwhelming Community Living and MCFD Intake caseloads.
• Where parental substance use issues are a concern, MCFD legislation permits investigating workers to access information from many sources about the acquisition and use of legal and prescription medications. All efforts to clarify how much of an impact parental substance abuse may impact child safety and care must be carried out.
• Parents complex health and their own management of chronic disease conditions is an important part of assessing capacity to care for the complex health care needs of their children.
• Calls that are received by MCFD that present ongoing concerns related to child safety must be registered as new intakes and full investigations completed. Written notes and lack of follow up with newly expressed concerns are an inadequate response to situations involving chronically marginal families.
• MCFD, Ministry of Education & Health develop a detailed strategy for provision of services to children and youth with special needs by Dec. 30, 2011, and fully implemented across the province by June 29, 2012.
• MCFD review plans of all children and youth transferred from CLBC to ministry services, to ensure vulnerable children and youth have appropriate plans that address both their safety as well as their needs. The review, along with a report to the Representative, should be completed by Dec. 30, 2011.
• MCFD develop and implement policy and guidelines with respect to checking with collateral sources of information when conducting child protection investigations.
• MSD work collaboratively with MCFD to develop a proactive policy and process so that income assistance to families with dependent children or youth with special needs will not be terminated without a joint review by MCFD and MSD. Policy and process should be developed by Dec. 30, 2011, and fully implemented across the province by June 29, 2012.

My own recommendation is that at all times, the human rights of children, must be seen to be the guiding force and paramount consideration of all systems of care in accordance with the United Nations Convention on the Rights of the Child.

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The Representative writes:

We all share a responsibility to be vigilant and aware of the circumstances of the most vulnerable children who live among us. Each and every one of us has a legal duty to report any concerns about a child’s safety and well-being to MCFD.

The ministry, in turn, has the responsibility to respond, assess these reports, investigate as appropriate and take necessary action to ensure that children are safe.

Duty to report need for protection

14 (1) A person who has reason to believe that a child needs protection under section 13 must promptly report the matter to a director or a person designated by a director.

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Report: Case of special needs girl left with mother’s corpse highlights deeply flawed system of supports in BC

By Lindsay Kines, Times Colonist, June 27, 2011.

BC disabled services rapped after girl left with corpse

CBC News, June 27, 2011.