Monday, October 3, 2016

Report to the Minister of Justice and Solicitor General - Public inquiry into the death of J'Lyn Michelle Cardinal -June 02-2016----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.----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.-------------------------

I am surprised that there has been nothing in the news about the fatality report on this child.

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Cardinal.aspx/DispForm.aspx?ID=277

Report to the Minister of Justice and Solicitor General - Public inquiry into the death of J'Lyn Michelle Cardinal 

June 02, 2016
The report concluded the 4-year-old’s cause of death was cranial trauma with a large blood clot pressing on the surface of the brain.

I will go over the report while I wait for the fatality reports from the folks who died in the custody of police and the folks who died after elopement from Rockyview General Hospital. It seems that there are repeated adverse events occurring in Alberta for no darn reason and there needs to be some changes to prevent repeated fatalities. Since government isn't in a hurry to do this work, I guess I will document the lack of progress.

In this case a child was in a Kinship arrangement and it appears that government didn't do much to supervise the care of the kid so the child died.  Unsurprising. Let us go over the lack of oversight that results in predictable results of our most vulnerable children.

J’Lyn Michelle Cardinal ---4 years old--died at the family home.  The folks involved in her birth and death are all family. The folks who were supposed to provide oversight was the government of Alberta.
Here are the family folks who are not identified.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-cardinal.pdf

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
****
J'Lyn Michelle Cardinal was born January 30, 2004. She was handed over to her aunt along with her five siblings August 2008 when she was four years old. She lasted until "January 13, 2009, she was just seventeen days short of her fifth birthday".
We are not given the details of the suffering of this child because the judge cuts the information out of the report. She tells us there is no point to elaborate since the aunt is being charged and the kid is dead:

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. 

****************
I disagree with the judge. The extent of the abuse is relevant since this would indicate to the public the extent of failures of the government in terms of oversight of this child.


We at least get some information of what the police found when the child was discovered dead:


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. 

**************************************************
So a child was abused and killed while in the care of the family in what is a kinship arrangement and government has no consequences for the failures in this case? How is this possible? I go look at Kinship arrangements in Alberta. 


Kinship Care

Kinship care is one of several placement options in Alberta for children who cannot live with their family because of concerns related to their safety and well-being, such as abuse or neglect.
Kinship care is a family home that is approved to care for a child in need because of a family connection or significant relationship to the child, (e.g. grandparent, aunt, close family friend). It is similar to foster care in the types of supports that are provided to the child and to the caregivers.
Kinship caregivers provide:
  • a child with love and care in a familiar setting
  • parents with a sense of hope that their child will remain connected to their birth family
  • families with a sense of trust, stability and comfort
  • an ability to support and maintain lifelong traditions and memories
  • support to a child in building healthy relationships within the family
  • guidance and reinforcement of a child’s cultural identity and positive self-esteem
***************************************************
So this is the Kinship program where they try to put children with family first. But how do they check if the family is fit for this program? Government has to approve of the family that decides on this arrangement.


Becoming a Kinship Caregiver

Who can be a kinship caregiver?

Kinship caregivers are family members or those with a significant relationship to the child. Kinship caregivers may not be the biological parents or any person whom has taken private guardianship of the child.
Kinship homes provide care for a specific child and do not accept other children as foster children.
Financial supports are available to help a kinship caregiver with initial set-up costs to provide for a child coming into their home.

Eligibility

Kinship caregivers are men or women who are at least 18 years old who are related to or have a significant relationship to the child. They can be married, single, divorced or widowed, and come from all cultural backgrounds. They may rent or own their own home, be retired or employed outside the home.
If you meet the following criteria, you may be eligible to become a child’s kinship caregiver:
  • You must be a resident of Alberta.
  • You must be at least 18 years old. The maximum age will be determined by the best interests of the child.
  • Any adult, regardless of marital status, can be eligible to be a kinship caregiver. Cohabitating applicants must be in a stable relationship for at least 12 months prior to applying.
  • You must be physically and mentally capable of meeting the child's needs with no major illness or trauma in the past 12 months.
  • Applicants must be financially stable and living within their means.

Process

Prior to placing a child with a kinship caregiver an initial screening that includes a criminal record check, a child intervention check and a home safety check must be completed. Once these initial checks are done, a child may be placed with the caregiver on the condition that the full application process is satisfactorily completed.
The child’s caseworker will help the applicant complete the application process which consists of:
Application, including:
  • three personal references
  • medical reference
  • criminal record check
  • child intervention record check
Attendance at Orientation to Caregiver Training consisting of eight, three-hour training sessions. These classes will give you an overview of what to expect when caring for a child, such as child development, special needs of children in care and supports provided to kinship care providers.
Completion of an approved home study. The home study determines if the applicant can provide a safe and suitable home for children and addresses a variety of topics such as family history, parenting skills and home safety.


*********************************
There is chatter here about a criminal record check. Did the government do this in this child's case?Also did the government review the suitability of the candidate?  Did they look into her ability to take care of not just one kid but SIX kids?


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

************
During the brief time that J'Lyn was with her aunt there were few at home visits that might have clarified the problems at the house:

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. 
****************
January 30, 2004--Birth
August 19, 2008--Kinship Caregiver application
September, 2008 --six children begin to live with aunt
November 3, 2008--no face to face visits after this date. 
January 13, 2009-Death


Between August 19, 2008 to January 13, 2009---the government did this:

five face-to-face visits with 
S.D.C. and eighteen telephone contacts

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. 

no face-to-face visits transpired after November 3, 2008.
*******************
So the government was considering splitting up the kids between the aunt (SDC) and the grandmother (FN). But there were no face to face visits between November 3, 2008 to January 13, 2009.
So what happened between November 3, 2008 to January 13, 2009?

There is evidence that the child never made it back after the Christmas break:

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
***************************

It is mind boggling that no one bothered to check into the absence of this child other than a phone call.  How could a child miss two weeks of school without any sort of investigation by the school or the government of Alberta? Where is the communication between systems? 

More importantly why was there no investigation by Human Services into the mental stability of the caregiver which was very problematic as noted here:

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.

****************
The government of Alberta seems to have presented the business aspects of the arrangement to the judge who quite rightly indicated in her report that the financial arrangements aren't the problem but certainly there appears to be other problems.

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. 

************************************
It appears that government has done a review and remedied the problems that are obvious in this case of poor selection of the caregiver, little inspection of the mental health issues, over packing the caregiver with too many children to look after (I mean SIX kids!!!) and then ignoring the children after the dump  was made.
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. 
***
Maybe they now do some home visits to check if kids are being beaten to death?

Where is this review? Looks like they didn't do any sort of checks before this review. As the judge pointed out this isn't a good system:
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. 
********************
In addition to the investigation of the caregiver it's no use having rules and regulations and no oversight. I mean we see this sort of chatter in the foster care system and in continuing care systems and it also seems to be now prevalent in the kinship program that there are rules / regulations and standards but what is the point of all these laws and regulations based on these laws if no one is held accountable for not following these rules of the game? It boils down to having everything documented and when the documentation shows failures, there needs to be penalties. But will this happen? Nope. This is after all the government and we know no one is held accountable for errors, adverse events and deaths in government. Only citizens are held accountable as this aunt was.  But what about the government's role in this mess? No penalties.  


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. 

Apparently the 2011 report indicated that they not stuff too many kids with the kinship provider but this recommendation was of course not followed. I guess it's a money problem.

Despite the 2011 report also including this recommendation, it has not been 
implemented for reasons set out by Ms. Ross.

*********************
 I go look at the report that I find here:

http://open.alberta.ca/publications/4632561

Kinship care review report










Kinship Care Review Report 
November 2009 

Summary of Recommendations for Improvement 
1. Collaborate with the Solicitor General to develop a provincial process enabling caseworkers 
to receive a criminal risk assessment of a kinship caregiver within 48 hours of placing a 
child. 
2. Develop policy regarding timely and frequent contact with the kinship care providers and the children placed when placement occurs prior to the completion of full approval activities. 
3. Strengthen policy to clarify that the Kinship Care Agreement must be signed within 48 hours 
of placement to enhance and support the kinship caregivers’ understanding of their role and 
responsibility associated with caring for a child in government care. 
4. Enhance policy to include a kinship care support plan that addresses circumstances unique to 
the kinship care provider’s capacity to meet the needs of the children being placed (such as 
the number and ages of the children). 
5. Support kinship caregiver training by modifying the current foster care Orientation to 
Caregiver Training so that it has enhanced relevancy to issues related to kinship care. 
********************************
So basically this report is all about yapping about recommendations that aren't followed by government. The judge has to repeat the same recommendation made in 2009.
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. 

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 
*******

The point of all these reviews and fatality reports should be to bring about system change.
Instead we see these reviews and reports as ongoing documentation of failures of government to do the right thing by our families.
We see these pieces of paper as evidence of the incompetence of the system to deal with ordinary and complex problems in families.
What can we do about these failures?
I'd say that we yap day and night to get this information out to all citizens.
Maybe it will wake up a small activist group of citizens to get government to the point of actually changing people, processes, oversight and imposing penalties for failures in staff performance and outright omissions of duties.
Maybe one day citizens will be able to do what government simply refuses to do which is keep our most vulnerable citizens safe.  

I'd say the exposure of these PREVENTABLE fatalities is essential and where the heck is the media?

Why are stay at home mummies doing the jobs of the free press?
And would J'Lyn Michelle Cardinal be alive today if the government of Alberta had the processes in place that it should have had in place to determine that putting six children with a relative with mental health issues was not a good thing to do? SDC had SIX children between eight months to seven years to care for with her partner. That is a lot of children. And why did no one in government think that this was a burden that might have repercussions for the children? I guess the kinship arrangement would cure all the problems of too many children to take care of. J'Lyn Cardinal lasted between September 2008 to January 13, 2009 and who knows what she suffered. We don't know. We only know how it all ended. 


September, 2008 --six children begin to live with aunt
November 3, 2008--no face to face visits after this date. 
January 13, 2009-Death


Home Study Report 
A home study is a comprehensive evaluation of family functioning and suitability to parent. 
The home study practitioner gathers and analyses demographic, relational and financial 
information, and evaluates how family dynamics, applicant history and the physical environment 
will impact the safety of a child placed in the home. Home studies must be completed by a 
qualified professional, most often a Registered Social Worker or other professional with relevant 
education and experience. 
Medical Reference 
Kinship care applicants must provide a medical report from a physician confirming their 
capacity to provide care for the child. The report provides a medical opinion concerning the 
general physical and mental health of the applicant. 

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.

http://www.huffingtonpost.ca/2016/06/15/jlyn-cardinal-alberta-inquiry-care_n_10484894.html





J'Lyn Cardinal's Fatality Inquiry Shows How The Alberta System Failed Her

Posted: Updated: 





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eranicle via Getty Images
A fatality inquiry has exposed the heartbreaking story behind an Edmonton preschooler's death.
"This is a very sad and complicated set of circumstances," said Provincial Judge Joyce Lester in a report, which explained how a inexperienced caregiver with a troubled past came to be the guardian of her brother's six young children.
The woman, who is identified as just S.D.C. in the report to protect the other kids' identities, pleaded guilty to manslaughter of her four-year-old niece J'Lyn Cardinal in 2010.
Cardinal died from a major head injury; police found her lying on her back, wearing only a diaper on the floor of her aunt's home.
At the time, S.D.C. was taking care of six kids aged eight months to seven years.
"This is a very sad and complicated set of circumstances."
S.D.C. grew up in a family that received assistance through child services. She was hospitalized for mental health struggles and was allegedly abused as a child, according to the inquiry report.
When she was just 23, she applied to become caretaker of the kids. Her brother and the children's mother were both struggling with homelessness and addictions.
For the first few months of taking care of the kids in 2008, S.D.C. brought them to appointments and school. In the weeks leading up to her death, Cardinal started missing school.
Aunt was 'essentially on her own'
S.D.C. wasn't receiving support from her extended family, and Kinship Care — the program that made her the children's guardian — rarely visited her home.
"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," the report reads.
On Jan. 12, 2009, the day before Cardinal's body was found, S.D.C. spoke on the phone with a social service worker about possibly bringing in her mother to help her with taking care of the children.
'A troubling situation'
Alberta's Kinship Care program was established under the premise that the best place for children in need is with their extended family, rather than in a stranger's foster home.
"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," reads the inquiry.
The judge's inquiry offered recommendations for preventing similar tragedies to Cardinal's death. It suggested that caregivers not be overburdened with too many young children, and that the program look into how experienced the caregiver is.
It noted there should be an extensive look into prospective caregiver's backgrounds, rather than relying on them to self-report.
The judge also recommended employees of the care program spend more time prepping caregivers and checking in on them in order to give them as much support as possible.
Four children have died so far this year while in government care, which includes foster homes.
S.D.C. is currently serving a seven-year sentence for Cardinal's death.

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