Monday, October 17, 2016

Report to the Minister of Justice and Solicitor General - Public inquiry into the death of J'Lyn Michelle Cardinal -June 02-2016----------------Medical Cause of Death: (“cause of death” means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)). Cranial trauma with a large blood clot pressing on the surface of the brain. Manner of Death: (“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable – The Fatality Inquiries Act, Section 1(h)). Homicidal ---3) You haven’t told me how to get the transcript of the court proceeding for either the fatality hearing or the criminal case. This is not information that is available from the OCME. You may wish to contact Transcript Management Services at: https://albertacourts.ca/resolution-and-court-administration-serv/transcript-management-services --

I went to the neighbourhood near my place as I was curious about these houses that were the size of Kansas. One house is about ten times the size of my house and I can't imagine how a family would rattle around in it. The house is enormous and has endless rows of windows. Other houses in the area were large as well but not as behemoth as this one.

The fake marsh that is next to these houses isn't as pretty as the fake marsh near my house. Their fake marsh has rocks and boulders plus a river format that is ingenious since it must require a massive pump system but it does not feel very natural. They have these rocks, fir trees and rose bushes stuck like knives in cake so their fake marsh looks very fake. My fake marsh in contrast is tiny and messy. It has reeds, noisy frogs (in the summer) a cluster of red winged blackbirds that seem to fight with the magpies that are endemic in my area as well as the odd seagull or two. The grasses get regularly overgrown, the willow trees are blackened corpses and there are pebble paths to the viewing areas. In the summer the Canada geese fight it out there and there are sundry duck couples making nests and ducklings. It's just an untidy place full of interesting things to see whereas the fake marsh near the supersized mansions was just a rigged up system of water channels pumping run-off water from one place to another. With fake waterfalls to boot.



After visiting the palatial homes in my usual nosy way,  I came back to my house and did more decluttering. I have got through the book case in my bedroom. I only have the bookcase outside my writing room. I may finish the top floor of the house soon.


Supper was the soup I made from the half of a chicken roast remnants plus sundry leftovers.  I got a box of mandarin oranges that were fresh and there are apples galore. I could not find the honeycrisp apples we are addicted to so they may be gone for the year. Too bad. They are sooo good.


I looked at my e-mails and I got this one back from the government saying that they can't give me autopsy results just because I am curious. They can't give me autopsy results in the public interest either. In Alberta they can't give you any information because it is cover your butt everywhere.


I want the autopsy results because the judge at the fatality hearing did not allow the revelations of the autopsy for some odd reason be too in-depth. I mean where else would this autopsy be discussed? But no, not at the fatality inquiry and now I guess never since I can't get the report. Alberta must be the province where information is worth more than your virginity.


Here is the fatality report and the non-existent autopsy information:
https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-cardinal.pdf


J’Lyn Michelle Cardinal
On January 13, 2009, Edmonton Police Service communications received a call from Emergency
Medical Services, indicating that emergency medical officers were at a residence where a five
year old child was found deceased in a bedroom.
This child was J’Lyn Cardinal, and as it was further investigated, it was determined that her actual
age was four years old.
When police members responded to the home, they noted the victim lying face up on a bedroom
floor, and she was wearing only a diaper. The deceased had bruising throughout her entire body,
and dried blood by her nose and mouth. As well, there was blood on the pillow of the bed, on the
bed itself and the bedroom floor. The autopsy report concluded that, in addition to the external
contusions and abrasions, the deceased had two fractured ribs, was dehydrated and a lethal
head injury caused her death. J’Lyn Cardinal was found dead by Emergency Medical personnel
at 0824 hours on January 13, 2009.


Dr. Melanie Lewis’ evidence need not be discussed in detail. She provided an extensive amount
of medical information as to the extreme abuse suffered by J’lyn, the brutality of which need no
further comment, given both the outcome of the criminal charge and the demise of the child.


**************************
Frankly speaking I don't see why the public can't hear about this autopsy in detail. Might wake up folks to the failures in the care of mostly aboriginal children in care.


Here is the brush off about the autopsy results:


From: JUST OCME Admin <OCME_Admin@gov.ab.ca>
Date: Mon, Oct 17, 2016 at 11:28 AM
Subject: RE: autopsy report
To: Julie Ali <


Dear Ms. Ali:
Thank you for your email of October 4, 2016 requesting information relating to a public inquiry.
The Office of the Chief Medical Examiner (OCME) is part of Alberta Justice and Solicitor General, a public body under the Freedom of Information and Protection of Privacy Act.  In the absence of consent from the next of kin or personal representative, we are unable to share any specific information with you.
You had several questions in your email regarding obtaining information.
1) Can you only order an autopsy result if you are the next of kin?  If you are a third party (interested citizen) how can you obtain a copy?
The OCME may release certain reports within the authority of the Fatality Inquiries Act.  Copies of the Certificate of Medical Examiner and copies of the detailed examination report, including the toxicology report can be released by the OCME upon receipt of a signed authorization by an adult next of kin of the deceased and upon payment of the associated fee.  Next of kin of a deceased person is mother, father, brother, sister, spouse, adult interdependent partner, or child.
Persons granted interest party status are generally found to have a direct legal and often economic interest in the decision that is being made.  It is taken into consideration the nature of the relationship between the person claiming to be an interested party and the actual parties in the dispute.  When there is such a relationship, the party is ‘interested’ because he or she stands to be impacted by the decision.  Simply being curious about the outcome is not sufficient to demonstrate that one is an interested party.
2) Can you waive fees for this case as it is in the public interest to know what happened to this child – something that was not revealed to us in much detail in the fatality report because the judge did not go into detail.
An autopsy report is not disclosed for public interest.
3) You haven’t told me how to get the transcript of the court proceeding for either the fatality hearing or the criminal case.
This is not information that is available from the OCME.  You may wish to contact Transcript Management Services at:
https://albertacourts.ca/resolution-and-court-administration-serv/transcript-management-services
There are privacy implications to the OCME regarding requests for personal information related to individuals whose deaths were investigated by us; the OCME is compliant with the Freedom of Information and Protection of Privacy Act and Fatality Inquiries Act legislation and as such does not disclose personal information to a third party.
The OCME is committed to maintaining the privacy of the personal information of the individuals involved in our investigations and thank you for your understanding of our policies.
Office of the Chief Medical Examiner - Edmonton
Alberta Justice & Solicitor General
780-427-4987


Confidentiality Caution:
This message is intended only for the use of the individual or entity to which it has been addressed and may contain information that is privileged and confidential.  If you are not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited.  If this communication has been received in error, respond immediately via telephone or return e-mail and delete all copies of this material.
From: Julie Ali
Sent: Tuesday, October 04, 2016 4:52 PM
To: JUST OCME Admin
Subject: Re: autopsy report
Hi,
I have looked at these forms.
1) Can you only order an autopsy result if you are the next of kin? If you are a third party (interested citizen) how can you obtain a copy?
2) Can you waive fees for this case as it is in the public interest to know what happened to this child -something that was not revealed to us in much detail in the fatality report because the judge did not go into detail.
3) You haven't told me how to get the transcript of the court proceedings for either the fatality hearing or the criminal case.
Sincerely,
Julie Ali
On Tue, Oct 4, 2016 at 1:09 PM, JUST OCME Admin <OCME_Admin@gov.ab.ca> wrote:
Hello, you may find our website helpful as it has links for the forms required to request documents
https://www.justice.alberta.ca/programs_services/fatality/ocme/Pages/DeathRelatedDocuments.aspx
Ordering OCME-issued documents
To order an document – as a next of kin – fill in the Request to Access Information form - 26 KB Download Adobe Acrobat Reader.
To authorize a third party to receive a document, fill in the Consent to Disclose Information form - 38 KB Download Adobe Acrobat Reader.
From: Julie Ali
Sent: Tuesday, October 04, 2016 12:35 PM
To: JUST OCME Admin
Subject: autopsy report
Hi,
1) How do I obtain the autopsy report associated with this fatality report:


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-cardinal.pdf
Report to the Minister of Justice and Solicitor General - Public inquiry into the death of J'Lyn Michelle Cardinal


June 02, 2016
On January 13, 2009, Edmonton Police Service communications received a call from Emergency
Medical Services, indicating that emergency medical officers were at a residence where a five
year old child was found deceased in a bedroom.
This child was J’Lyn Cardinal, and as it was further investigated, it was determined that her actual age was four years old.
When police members responded to the home, they noted the victim lying face up on a bedroom floor, and she was wearing only a diaper. The deceased had bruising throughout her entire body, and dried blood by her nose and mouth. As well, there was blood on the pillow of the bed, on the bed itself and the bedroom floor. The autopsy report concluded that, in addition to the external contusions and abrasions, the deceased had two fractured ribs, was dehydrated and a lethal head injury caused her death. J’Lyn Cardinal was found dead by Emergency Medical personnel
at 0824 hours on January 13, 2009.
Report – Page 3 of 6
LS0338 (2014/05)
S.D.C., during the initial police interview, provided no realistic explanation for J’Lyn’s injuries but came to admit, over time, that she was the person responsible for these injuries which led to the death. S.D.C. was charged with second degree murder, with an offence time frame between January 10, 2009 to January 13, 2009. S.D.C. pleaded guilty to manslaughter by way of an Agreed Statement of Facts, in the Court of Queen’s Bench, on October 22, 2010. She received, essentially, a penitentiary sentence of seven and a half years.
2) How do I get a copy of the fatality inquiry transcript?
3) How do I get a copy of the court of Queen's Bench proceedings for October 22, 2010 for S.D.C.'s case?
Sincerely,
Julie Ali
This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the system manager. This message contains confidential information and is intended only for the individual named. If you are not the named addressee you should not disseminate, distribute or copy this e-mail.


The only useful information from this run of questions is the possibility of getting transcripts for the fatality inquiry. Now that would be useful. But probably since this is Alberta the entire transcript has a code Blue attached to it and you can't get it if you aren't god.  Even god might have problems trying to get any useful information in Alberta.

The entire fatality report is here:

LS0338 (2014/05)

Report to the Minister of Justice
and Solicitor General
Public Fatality Inquiry




Fatality Inquiries Act

WHEREAS a Public Inquiry was held at the Edmonton Law Courts
in the City of Edmonton , in the Province of Alberta,
(City, Town or Village) (Name of City, Town, Village)
on the 16th to 20th days of November , 2015 ,
year


before The Honourable Joyce L. Lester , a Provincial Court Judge,

into the death of J’Lyn Michelle Cardinal 4 years
(Name in Full) (Age)
of Edmonton, Alberta and the following findings were made:
(Residence)
Date and Time of Death: January 13, 2009 at 8:24 a.m.
Place: At the family home in Edmonton, Alberta

Medical Cause of Death:
(“cause of death” means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)).

Cranial trauma with a large blood clot pressing on the surface of the brain.

Manner of Death: (“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable – The Fatality Inquiries Act, Section 1(h)).

Homicidal
Report – Page 2 of 6


LS0338 (2014/05)


Circumstances under which Death occurred:



Given the recent amendments to Section 126 of the Child, Youth and Family Enhancement Act
(CYFEA), specifically referencing Section 126.3, it is noted that legal counsel for the department
of Human Services, Mr. Peter Barber, consents to the release of the name of the deceased child.
However, there is to be no publication of any material that would identify any of her siblings who
may have been in care, at the time, or who may continue to be in the care of Human Services. It
is further noted that the CYFEA contains provisions for family to apply to the Court to have the
name of the deceased child withheld from publication. No such application has been made, in
this case.

With respect to other family members addressed in the Fatality Inquiry Report, these persons will
be described only by initials:

S.C. - biological mother of deceased
D.C. - biological father of deceased

S.D.C. - paternal aunt/guardian of deceased
R.B. - common-law partner of S.D.C.

F.N. - paternal grandmother of deceased

Introduction

J’Lyn Cardinal was born on January 30, 2004. She was the third eldest child amongst a family of
six children, ranging in age from eight months old to seven years old. At the time of J’Lyn’s death
on January 13, 2009, she was just seventeen days short of her fifth birthday.

This young family of six children was placed under a Custody Agreement with their paternal aunt,
S.D.C., in August, 2008. Given the family relationship, there were proceedings being conducted
to manage the placement by way of a Kinship Care Agreement. However, the death of J’Lyn
Cardinal occurred prior to completion of S.D.C.’s home actually receiving approval as a Kinship
Care home. At the time of placement of J’Lyn into S.D.C.’s home, the biological father of J’Lyn
who is also S.D.C.’S brother, D.C., was in agreement with his children all residing with S.D.C.
Both D.C. and the biological mother, S.C., possessed an addiction to crack cocaine, during this
period.

On January 13, 2009, Edmonton Police Service communications received a call from Emergency
Medical Services, indicating that emergency medical officers were at a residence where a five
year old child was found deceased in a bedroom.

This child was J’Lyn Cardinal, and as it was further investigated, it was determined that her actual
age was four years old.

When police members responded to the home, they noted the victim lying face up on a bedroom
floor, and she was wearing only a diaper. The deceased had bruising throughout her entire body,
and dried blood by her nose and mouth. As well, there was blood on the pillow of the bed, on the
bed itself and the bedroom floor. The autopsy report concluded that, in addition to the external
contusions and abrasions, the deceased had two fractured ribs, was dehydrated and a lethal
head injury caused her death. J’Lyn Cardinal was found dead by Emergency Medical personnel
at 0824 hours on January 13, 2009.

Report – Page 3 of 6


LS0338 (2014/05)
S.D.C., during the initial police interview, provided no realistic explanation for J’Lyn’s injuries but
came to admit, over time, that she was the person responsible for these injuries which led to the
death. S.D.C. was charged with second degree murder, with an offence time frame between
January 10, 2009 to January 13, 2009. S.D.C. pleaded guilty to manslaughter by way of an
Agreed Statement of Facts, in the Court of Queen’s Bench, on October 22, 2010. She received,
essentially, a penitentiary sentence of seven and a half years.

Witnesses Presented to the Court

1. Glen Shaw - Social worker and initial caseworker assigned to the file
2. Ken Lynch - Generalist/front line investigator for Child & Family Services
3. Alfred Jeannotte - Supervisor with Income Support at Alberta Services
4. William Mullen - Supervisor with Human Services on the file
5. Leslie Block - Expert in the area of Forensic Psychology, Aboriginal mental health issues
and Aboriginal cultural and community factors
6. Richard Lemieux - Policy analyst with Human Services in the area of child
intervention
7. Dr. Melanie Lewis - Expert in the area of Paediatrics and child maltreatment; involved
with the file
8. Angela Ross - Program consultant and Policy developer with Human Services; involved
with Kinship Care programs, amongst other duties

It is important to note that Inquiry Counsel took great effort in attempting to present F.N. to the
Court to give testimony, but for unexplained reasons, that witness chose not to attend. Also,
although no active participation occurred as a result of the biological father’s attendance, for a
short time, at the Inquiry, it should be noted that he did attend for a portion of the evidence.

Circumstances Leading up to the Death

S.D.C., the aunt and primary caregiver, had a history with Childrens’ Services, as it was then
called, dating back to 2002. She was a child in need of government assistance, and she was
seventeen years old, at that time. It is important to note that the extended family, as well, was
known to participants in the child intervention system, and with the department now known as
Human Services. It is not necessary to detail each historical step along the way to August, 2008,
when J’Lyn Cardinal and her five siblings were brought to the attention of Human Services.

To begin, suffice it to say, that Mr. Glen Shaw was the intake worker on or about August 19,
2008. At that time, he was aware that S.D.C. had contacted the department for assistance in
becoming the guardian of her brother’s six children. S.D.C. was twenty-three years of age, and
in a common-law relationship with R.B. S.D.C. had a letter from the biological father asking that
S.D.C. become the guardian of his children.

It was determined that the biological parents were unable to care for the children due, in part, to
homelessness, and drug addictions. Rather than apprehend the children, a Kinship Care
placement process was initiated.

In the beginning stages and throughout, it appeared that S.D.C. had the capability to care for the
children. As well, it appeared that there were enough extended family members to offer her
assistance and support, when required.

S.D.C. and R.B. resided with all of the children from September, 2008 until the death of J’Lyn in
January, 2009.

Report – Page 4 of 6


LS0338 (2014/05)
During this time period, the department of Human Services had five face-to-face visits with
S.D.C. and eighteen telephone contacts, with some of those telephone calls occurring on the
same date, more than once. This information was extracted from the materials filed with the
Court. On January 12, 2009, the day before it was known that J’Lyn was deceased in the home,
there were two telephone calls recorded in the notes, where the focus of the discussion was on
having F.N. become more involved as a family support. In fact, consideration was being given to
splitting up the six children into two groups, where S.D.C. would care for some, and F.N. would
take the remaining children into her home.

Throughout the four and a half months that this Kinship Care application process was occurring,
in addition to all of the paperwork and documentation of visits; medical appointments needed and
carried out; school enrollment established; physical set-up of the home to prepare sleeping
accommodations for eight people, S.D.C. had few actual contacts with the department, by way of
personal attendance, at the home.

During the final few weeks of J’Lyn’s life, there were a few phone calls exchanged but, again, no
face-to-face visits transpired after November 3, 2008. Despite the Christmas season often being
considered a very stressful time for many families, in many homes, S.D.C., with her added
responsibilities and expanded family, was essentially on her own.

Amongst the voluminous filed materials, such as transcripts from other court proceedings and
police reports and witness statements, there are comments, as well, from school personnel about
concerns over J’Lyn’s lack of attendance after the Christmas break. Unfortunately, the caregiver,
S.D.C., was the only person contacted and she provided an explanation to the school staff that
was accepted at face value. Had the department been made aware of this extended absence,
perhaps a more intrusive approach as to what was happening in S.D.C.’s home would have been
undertaken.

Mr. Block, through his testimony as an expert in the area of forensic psychology, presented a
glimpse into S.D.C.’s background. Some of her personal antecedents included elements of
suicidal behaviour, hospitalization for mental health reasons and allegations of an abusive
upbringing. This post-offence material allows for a more thorough understanding of S.D.C.’s own
problems but was only investigated, extensively, after the criminal nature of the death came to
light.

Dr. Melanie Lewis’ evidence need not be discussed in detail. She provided an extensive amount
of medical information as to the extreme abuse suffered by J’lyn, the brutality of which need no
further comment, given both the outcome of the criminal charge and the demise of the child.

The witnesses presented from the government to explain the financial elements of the support
provided to S.D.C., as caregiver, are acknowledged but given the nature of this inquiry, the
evidence does little to assist in the formulation of any thoughtful recommendations, going
forward, in this particular case. The department has a very detailed protocol when it comes to
the financial support, transportation issues, costs dispensed for materials and furnishings needed
to address housing and daily living. This is not an area of concern in this case.

Finally, upon hearing from Angela Ross as to the philosophy and structure of the Kinship Care
Program, it appears that a lot of the steps that must occur before a placement is completed are in
existence, already. Since 2009, with the added changes to some areas of concern, as a result of
the government’s own review of Kinship Care, improvements have been inserted into the current
program structure. For example, there are now more frequent visits, person to person, than there
were in 2008, during the early months of placement.

Report – Page 5 of 6


LS0338 (2014/05)
Summary

This is a very sad and complicated set of circumstances. So many forces, human and systemic,
have collided. The best of intentions in securing a child into a home environment that is safe and
nurturing can be seen in the drafting of the Kinship Care Program. However, it is a troubling
situation and a fine act of balance when the kinship placement may well be as dysfunctional an
environment as the home from which the subject children are being extracted.

Assessing the chances of a successful outcome, without an in-depth examination of the previous
experiences of the caregivers own backgrounds, is risky. When it comes to the safety of
children, the best possible situation involves no risk. There can be no exact policy to apply to
eliminate risk, when it involves human behaviour and endless sets of circumstances, but only
strict adherence to the policy will reduce that risk.
Recommendations for the prevention of similar deaths:




1. There is little dispute about the value of the Kinship Care process and the need to keep
children safe, within a familiar environment amongst family members, where possible.
The philosophy of the program considers extended family to be the best and first
consideration, before apprehension of any form. However, it becomes troublesome when
the family members identified as potential kinship placements have a family history
fraught with dysfunctional characteristics of their own. When this first comes to light, or is
suspected, it is of the utmost importance that there be extensive, early background
assessments conducted on each and every adult in the home, within which children are
being placed. Self-reporting as to one’s own history is not always accurate. In addition,
reference letters have value, but should be followed up with a face-to-face interview.

Guidelines have been established in such areas of focus as family history, criminal history and
prior involvement with Human Services, (as it is titled today). However, a procedure to ensure a
caseworker/supervisor has ultimate responsibility to document that each area has been properly
and thoroughly investigated must be followed, and not just drafted. It is of no value to have the
steps in place, if no one can absolutely ascertain that each step has been successfully
completed. These steps, while entrenched in the structure of the Kinship Care process, can only
be beneficial with strict adherence to each step.

2. The number of children placed into a kinship care home should be established and
limited. Despite the 2011 report also including this recommendation, it has not been
implemented for reasons set out by Ms. Ross. This recommendation is being set out,
again, after this Inquiry.

Factors to consider when determining the number of children should include, but not be
limited to:

a. The age range of the children placed in the home;
b. The nature of the relationship, and its strength between the caregiver(s) and the
children being placed;
c. The caregivers’ experience in managing a household with children present;
d. The special needs of the children, if there are any documented; and
e. The extended family considered as alternative supports for the caregiver must reside
within the same community.




Report – Page 6 of 6


LS0338 (2014/05)
3. Since 2009, monitoring of newly established kinship care homes has increased in
frequency, during the first three months of the process. In addition to the scheduled
attendances, however, home visits should include a less formal, unannounced
attendance, at least once per month, depending on the circumstances of the placement,
during the initial six month period. Discretion as to which Kinship Care arrangements
would benefit from this additional spot check should be in the domain of the caseworker,
in consultation with the supervisor.

4. There are already manuals and program materials provided to caregivers in the Kinship
Care program, but it is not enough to leave the materials and expect the caregiver to
review and understand the materials. It would be advisable to have a time to review the
materials together, or re-attend to discuss the materials, having been satisfied that the
caregiver has actually absorbed what is in the materials. Educational background and
reading comprehension is not the same for all caregivers. Some method to assess the
usefulness of the materials provided needs to be established.

5. Little information was provided as to the relationship between the department and the
School Board, in relation to children in care. If the Kinship Care placement qualifies as
placing the department in a position where sharing of information is allowable, there
should be a process established between the school system and the department, wherein
any extended absence of a child in Kinship Care, should be brought to the attention of the
department, as well as the caregiver, in the same manner that any unusual physical
trauma or suspected abuse would be addressed by the school staff.

It has not been overlooked that since the tragedy that occurred with respect to J’Lyn Cardinal, the
Kinship Care program has introduced more details and procedures into the approval process.
However, the recommendations should emphasize the value in the process is only as successful
as the strict adherence utilized in following that process.
DATED April 19, 2016 ,


at Edmonton , Alberta. Original signed by

The Honourable Joyce L. Lester
A Judge of the Provincial Court of Alberta

No comments:

Post a Comment