Saturday, October 8, 2016

--don't wait for government------say the stories -----we aren't here to boast victory / we are telling the stories of system wide failures

and take your heart
like a sword
to cut through the muscle of the work
that is all about you
don't wait for government
instead take the time that is yours
to make the work perfect
this is the way

and take your heart
like a sword
and raise that sword
to protect the weak and defenseless
don't hesitate to speak for them
and shout out the news of incompetence
among the caregivers and their oversight bodies
this is the way

and take your heart
to calmly recount horror and abuse
to say the words of families decimated by these disasters
say the stories   this truth will be said to power
over and over until our words are heard
we aren't here to boast victory
we are telling the stories of system wide failures
this is the way


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a
Report to the Minister of Justice
and Attorney General
Public Fatality Inquiry
Fatality Inquiries Act
WHEREAS a Public Inquiry was held at the the Law Courts Building
in the City of Edmonton , in the Province of Alberta,
(City, Town or Village) (Name of City, Town, Village)
on the 17th to 21st and 27th day of January, , 2011 , (and by adjournment
year
on the 7
th and 11th day of February, March 18th, and on the 2nd to 4
th day of November, 2011
year
before Marilena Carminati , a Provincial Court Judge,
into the death of Samantha Lauren Martin 13
(Name in Full) (Age)
of Morinville, Alberta and the following findings were made:
(Residence)
Date and Time of Death: approximately 6:20 a.m., December 3, 2006
Place: Stollery Children's Hospital
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)).
Undetermined.
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)).
Natural.


Circumstances Under Which Death Occurred:
Introduction
The inquiry into the death of Samantha Martin was held pursuant to the Fatality Inquiries Act. Some
delay was occasioned as initially the view taken was that this was not a case which fell within the
purview of the Act; ultimately however, the Board decided that an inquiry was appropriate and a Fatality Inquiry was ordered on July 23, 2008.
The inquiry was held over a number of days, and heard from numerous witnesses. A large number of
exhibits were filed, including a large binder of medical records, Children’s Services records and other
documentation.
Samantha Martin was born to Velvet and John Martin on June 4, 1993. She was diagnosed soon after
with Tetrasomy 18p, an extremely rare genetic variation which gives rise to a number of symptoms,
including various developmental delays.
Samantha’s parents decided to place her in foster care, for a number of reasons, including their grief at
learning of the diagnosis, an unfortunately pessimistic prognosis and an unfortunate impression formed
by Mrs. Martin that foster care would offer Samantha greater special services than would be affordable
for her if she remained with her biological parents. Samantha was placed into foster care when she was
7 weeks old. She was placed with the Himschoot family near Morinville on August 3, 1993. A
Permanent Guardianship Agreement was signed on October 24, 2001. Samantha’s biological parents
were in telephone contact with the Himschoots, and reinitiated contact with their daughter, commencing when she was approximately 3 years old. Their contact with Samantha increased over time, and
eventually led to joint guardianship of Samantha on October 24, 2001. In April 2006 Samantha
increasingly spent time with the Martins, and eventually Samantha returned to live with her biological
parents, not long before her death at the age of 13. Samantha appeared to be thriving after returning to
her parents full time on June 27, 2006. Samantha gained weight, going from 49 pounds at the time of
her return, which was her approximate weight for the previous 3 years, to 60 pounds by the end of July
2006, and looking much healthier in photos taken after her return to her biological parents. Samantha
was nonverbal, but after her return home had started to acquire a few more words. In October 2006,
Samantha was seen by Drs. Watt and McIvor at the Glenrose Rehabilitation Hospital Physical Medicine Clinic and it was noted that she had gained 6 kg in weight and 2 cm in height since her examination one year earlier. According to the Information Consolidation prepared by Children’s Services, the plan was to rescind the Permanent Guardianship Agreement in December 2006.
The immediate circumstances leading to Samantha’s death
Tragically, Samantha became ill on November 29, 2006. She came home from school retching, and
began vomiting. She later experienced diarrhea as noted by Mrs. Martin. Samantha settled in the
evening and was left with her older brother while the Martins went to the bank, but unfortunately,
Samantha’s condition worsened. Her brother phoned his parents to say Samantha had stopped talking.
The Martins returned home, called an ambulance and Samantha was taken to the Sturgeon General
Hospital in St. Albert. She was subsequently transferred to the University of Alberta Stollery Children’s Hospital, where a decision was ultimately made to remove life support. She passed away on December
3, 2006. The fact that Samantha was on life support for a period of time contributed to the difficulty in
assigning a cause to Samantha’s death. It is known that her heart stopped; much less clear is why it
stopped.
Samantha’s past medical history
Tetrasomy 18p
The Court heard from Dr. Cody and Dr. Hale, a geneticist and pediatrician respectively, who are leading experts from the University of Texas at San Antonio with respect to this rare genetic condition. They have very extensive knowledge and experience with Tetrasomy 18p. They testified that to the best of their knowledge, it does not appear that Tetrasomy 18p is associated with any indications of reduced life expectancy. The condition is so rare that it is hard for them to give accurate estimates, but they felt it was probably one in 100,000. They have attempted through their research to understand the condition better, and have compiled a list of features common to many of the children who have this genetic variation, in an article which became Exhibit 4 in the inquiry. Based on this analysis, it appears that 21 per cent of the children with Tetrasomy 18p have seizures. Many have gastrointestinal difficulties, but other than feeding difficulties especially in the early years of life, the children with Tetrasomy 18p were not noted to be particularly thin or frail. Dr. Maryanne Thomas, a geneticist at the Alberta Children’s Hospital, also gave evidence in the inquiry that in her opinion there is no evidence of any link between Samantha’s Tetrasomy 18p and her death.
Samantha’s previous fractures and bruises
Mrs. Martin raised concerns at the inquiry about various injuries Samantha suffered while in foster care.
Children’s Services does not appear to have sought an expert opinion on the total number of fractures and the plausibility of the various explanations offered for them, or on the plausibility of explanations offered for various bruises which caused school staff working with Samantha to raise concerns with Children’s Services. Samantha herself was nonverbal, and could not be interviewed about these matters. However, although Samantha had a number of bruises on her face and neck and also suffered a number of fractures of her bones while in foster care, including fractures on two separate occasions of her thigh bone, it does not appear from the evidence that there was any causal link between these injuries and her death.
Samantha’s weight
Natasha Dancause [Kowalsky] became involved in Samantha’s case in January and February of 2006.
Ms. Dancause was a specialized investigator with Children’s Services who conducted assessments as
to level of risk screenings and to decide whether intervention was warranted. Reports were received
from several school staff members of scratches and bruises on Samantha’s head and neck that were
increasing in frequency since Christmas 2005, and concerns about the contents of Samantha’s lunch
compared to the larger more balanced lunches provided to the biological son of the foster parents.
School staff reported to Children’s Services that when this was raised with the foster mother, the
response was to tell the school to fill Samantha up with water. There was particular concern because
Samantha only weighed approximately 51 pounds at 12 years of age and had gained only 2 pounds in
2 years. The screening conducted by Ms. Dancause involved speaking to caseworkers and support
workers involved with the child (Valerie Jensen) and the family (Lynn Bell) and to the people from
Samantha’s school. Ms. Dancause also had received a letter forwarded through Mr. Brian Leonard,
February 16, 2006 from Samantha’s biological mother, received in November 2005, which outlined a
number of concerns about Samantha’s care in the foster home. Ms. Dancause did not meet with
Samantha and did not make any calls to any doctors responsible for Samantha’s care. She relied on
case workers and support workers to share information. There were disagreements and issues arising
generally between the biological and foster parents. Ms. Dancause decided on February 21, 2006 that
the complaints raised about Samantha’s care did not require an investigation. The lack of records of
medical checkups noted in a Children’s Services file review from December 2005 seems not to have
been on the radar.


Dr. McGonigle is the pediatrician who saw Samantha from time to time when her foster parents brought her in. He noted it was not a very thick file for someone with Samantha’s condition. He usually sees kids like that once every 3 months, and at least once a year for a complete checkup. In contrast, he saw Samantha for the first time in 2000, with a complete checkup in 2002, one when she was 8, and in June 2004. When she became his patient he was not able to obtain the file from the previous doctor who had cared for her. Her sparse visits might mean that she was relatively well. At age 11 Samantha was below the 5th percentile for weight and gained fairly little after that. Dr. McGonigle testified that low weight would be the result of low caloric intake. It does not appear from the evidence that the low weight was the result of Samantha’s Tetrasomy 18p, and it appears that Children’s Services staff may have erroneously attributed her low weight to her genetic condition. However, Dr. McGonigle felt that
Samantha’s underweight status which lasted for some years would not have been a contributing factor
in her death, because when Samantha was returned to her biological mother and gained a healthy
amount of weight, that would have countered any problems that would otherwise have been caused by
the previous low weight. The autopsy report indicates that Samantha weighed 42 kg and was 1.42 m
tall at the time of her death. Dr. Dowling, the pathologist, also testified that the fact that Samantha
weighed far less than she should have for a considerable length of time was not a factor he could
connect to her death in light of the other difficulties establishing a cause of death. Accordingly, it does
not appear from the evidence that Samantha’s underweight years were a contributing factor in her
death.
Whether Samantha suffered from seizures
Lorna Huff testified at the Inquiry. She was the assigned caseworker for Samantha Martin from
September 1998 to August 2005. She does not have a degree in social work, which is not required in
the province of Alberta, but did have an education degree and was a registered social worker. Her
responsibilities included seeing the child, having contact with the foster home, to be aware of everything that was going on in terms of the care Samantha was receiving, to talk to the doctors, to the foster mother, and to see the child in face to face visits, as well as having contact with the biological mother, to ensure the child’s best interests were met. A case conference was held at Samantha’s school
November 21, 2002, where concerns were raised by the school that there was a possibility Samantha
might be suffering from seizures, and suggesting that the doctor be consulted with respect to an
encephalogram to rule out a seizure disorder. A report was prepared setting out in detail the substance
of the meeting and the recommendations (Exhibit 6). Mrs. Huff’s notes from the case conference
indicate “E.E.G. to rule out seizure disorder” and the note had a star beside it to indicate to Mrs. Huff
that it was important to follow up on. Although Mrs. Himschoot and Mrs. Martin were not at the case
conference, Mrs. Huff felt the foster mother was aware of the seizure issue, and testified that “Joanie
was very attentive to the child’s medical needs,” “very often” took Samantha to the doctor, and “would
have followed up with Dr. McGonigle.” Dr. McGonigle was not advised of seizure activity by Mrs.
Himschoot, and never received a copy of the consultation report which referred to the need to assess
for possible seizures. Dr. McGonigle testified that if he had seen the report he would have assessed
Samantha for seizures. He testified however that not all children with seizures are placed on
medication. Dr. DeCaen, another pediatric expert, also testified it is possible seizures might not be
treated. Dr. DeCaen indicated that would be a decision that should be made by a physician.
Five days after the November 21 case conference, there was a further meeting (this time an Individual
Program Plan meeting to discuss Samantha’s educational goals) at Samantha’s school where many of
the same individuals were present, as well as the foster mother and the caseworker. Although the
records do not indicate that the issue of possible seizures was addressed at this meeting, it does
appear that the foster mother indicated that she planned to take Samantha to Dr. McGonigle for a
medication review. On December 3, 2002, the foster mother advised Mrs. Huff that Dr. McGonigle had increased Samantha’s medication and asked that the school document their concerns. It is not clear
whether the issue of possible seizures was ever discussed during this phone call, but the contact notes
from the Children’s Services file together with Dr. McGonigle’s records and evidence appear to suggest the issue discussed was Resperidal which was being prescribed for behavioral issues and which had nothing to do with seizures. Mrs. Huff believed that Mrs. Himschoot had a lot of experience with medically fragile children, as a large number of such children were placed in her care, and Mrs. Huff appears to have been under the impression that Samantha had monthly visits with doctors. However, this does not appear to be an accurate understanding, as an EEG was never sought by the foster mother for Samantha, and although the foster mother did take Samantha to the doctor from time to time for various needs, she did not bring her for regular physical checkups with the pediatrician. The health records disclose a period of 3 years where Samantha was not seen by a pediatrician or family doctor (Exhibit 21shows a gap from 1997 to 2000, viewed in light of Mrs. Himschoot’s evidence that Dr. Berhmann was the pediatrician before Dr. McGonigle, and then briefly Dr. Janika). This was unusual for a child with her complex medical needs, according to Dr. McGonigle and Dr. DeCaen. Mrs. Huff, although she was the caseworker for Samantha, appears to have been ill informed as to the frequency or nature of Samantha’s medical visits, and relied heavily on what the foster mother told her was going on. Mrs. Huff did not notify Dr. McGonigle, the pediatrician, about the suggestion that an encephalogram be done to rule out a possible seizure disorder. She assumed the foster mother, who was not at the case conference, had done it.
Mrs. Huff never attempted to confirm with Dr. McGonigle or Mrs. Himschoot that the seizure issue had been assessed by the doctor. Mrs. Himschoot testified she did not convey a concern about seizures to Dr. McGonigle, as she felt she would want to know more before going to a doctor, and testified that she feels the same way now. Mrs. Huff testified that she spent time with Samantha and never saw any seizure activity. Exhibit 6, a Consulting Services report which discussed the school’s concerns about possible seizures, was shown to Mrs. Huff, who indicated she had received it but did not forward the document to Dr. McGonigle; she did not know if the report was sent to the foster mother or biological mother. The consultation report recommended that the report be forwarded to Dr. McGonigle as well as data collected about Samantha’s performance and behaviour at school so that Dr. McGonigle could assess the information prior to seeing Samantha. The school felt that it required written permission from the foster mother prior to forwarding the report to Dr. McGonigle. Mrs. Huff felt “it did not seem to be a big issue”.
Mrs. Huff was required to have in person visits with Samantha at least once every 3 months, but longer periods went by; 14 months went by with no face to face visits according to Children’s Services’ internal review, during the period from July 12, 2001 to September 19, 2002, but Mrs. Huff testified she did not document two in-person visits, as paperwork was not her strength. There were also gaps of 7 or 8 months at times, although Mrs. Huff sometimes visited Samantha more than once every 3 months. Mrs. Huff testified that her case load made it difficult to keep up with her paperwork. (A previous worker for Samantha also had had only 3 face to face visits with Samantha during the 26 month period from February 1996 to April 1998 (according to the Children’s’ Services file review), whereas policy would have required at least 8 or 9 visits in that kind of time frame. Mrs. Huff took over in September 1998.
Lorna Huff testified that Samantha’s condition came with difficult behavioral issues and Mrs. Huff felt
she would never have been able to find a placement for Samantha that would have been equal to let
alone better than the quality of care she was receiving in the foster home.
Valerie Jensen took over from Lorna Huff in 2005 as the Children’s Services case worker for Samantha. On September 15, 2005, a Children’s Services review of the file found no record of annual medical or dental checkups. A further December 2, 2005 review of the file was completed by Diane Martin who noted that there had been no face to face meetings with Samantha since February, and also again noted that there was no indication of annual medical/dental checkups in the file. It appears there were no face to face visits documented with Samantha after February 2005 until
November 23, 2005, and then again until March 21, 2006 (then June 13, 2006) notwithstanding the
December 2, 2005 review.
The comprehensive file review by Children’s Services prepared after Samantha’s death (dated June 4, 2007) notes that the last medical report on Samantha’s file as of June 2006 was from Dr. McGonigle on June 15, 2000. (Alberta Health Services billing records indicate a visit with Dr. McGonigle on June 14, 2000 which is categorized as diagnostic evaluation, limited, not requiring the taking of a complete history/evaluation.) The foster mother provided details to Valerie Jensen about Samantha’s recent medical visits, which the foster mother indicated was with Dr. McGonigle December 29 of 2005. (It appears from AHS billing records that there was also a visit April 19 of 2006.)
Upon her return to the biological parents, the Martins, Samantha was taken to the pediatrician Dr.
Roseman, who on November 15, 2006 arranged for an EEG to investigate the issue of seizures, after the biological mother and a teacher of Samantha’s had witnessed what they felt might be seizures; this EEG was to have taken place on November 30, 2006. An earlier EEG that Mrs. Martin had scheduled October 16, 2006 with Dr. Starreveld was inconclusive. Mrs. Martin testified that Dr. Roseman witnessed a seizure in the office on November 14, and her communication log with the school aid Carla for November 14, 2006 certainly appears to bear this out, but the doctor did not recall the incident, although he felt he had been confident they were dealing with seizures. (Mrs. Martin also told Children’s Services in September 2006 that she had told the foster mother in 2002 about her concern about seizures in children with Testrasomy 18P but nothing was done; this was documented by way of a letter that Mrs. Martin had sent to Mrs. Himschoot. Mrs. Martin had sent a letter to the foster mother dated October 4, 2002 suggesting Samantha be checked for seizures as a result of her research on Tetrasomy 18p disclosing it to be quite common in children with Tetrasomy 18p.)
On Samantha’s November 15, 2006 examination by the pediatrician, Dr. Roseman, Samantha
appeared to be doing well and weighed 61 pounds, but Samantha passed away before Dr. Roseman
had a chance to complete the investigation into whether she required treatment for seizures.
The issue of possible absence seizures had been raised long before, by the Physical Medicine Clinic at the Glenrose Rehabilitation Hospital, on June 4, 1996, when Samantha was 3 years old. In a composite report prepared by S. Acheson, R.N., the Coordinator for the Physical Medicine team, it was noted that the foster mother was advised to discuss the issue of the possible absence seizures with Dr. Berhmann, who was at that time Samantha’s pediatrician, as the nurse felt she had seen what could be absence seizures during the clinic that day. Dr. Berhmann’s file was not available to the inquiry, as it was picked up by Mr. Himschoot in 1997 and apparently misplaced or lost. The report does indicate a copy was being sent to Dr. Berhmann. It appears however from Mrs. Himschoot’s evidence that the seizure concern likely was not followed up on. It appears from the Alberta Health Services records that Samantha was last seen by Dr. Berhmann on August 6, 1996 (the only visit with this doctor after the Physical Medicine Clinic referred to above). However the records indicate the August 6th appointment was for “diagnostic interview and evaluation, described as limited (visit not requiring complete history and evaluation)”.

What conclusions if any can be reached about the cause of death
Numerous doctors testified at the inquiry. Dr. Idikio conducted the autopsy on Samantha at the
University of Alberta Hospital. He could not determine a cause of death. He indicated that some
damage to the lining of the colon leading to sepsis was a possibility, but he had insufficient evidence to determine whether that had in fact occurred.
Dr. Adrian Jones testified. He is a pediatric gastroenterologist. He did not see Samantha as a patient,
but reviewed extensive medical records and provided the Court with his opinion. He was of the view
that a possible cause of death was perhaps a laryngospasm due to a minor reflux of acidic fluid from
the stomach which was possibly aspirated onto Samantha’s larynx. Dr. Adrian Jones felt sepsis was not a likely cause of death as there were no indications of abnormalities in Samantha’s liver; however he could not rule it out as a possible cause of death. Dr. Jones could not say definitively that laryngospasm was the cause of death. No food debris was observed by medical staff when Samantha was intubated, but Dr. Jones felt that this could be because Samantha had not eaten for several hours, or that the laryngospasm may have been triggered by acid rather than food particles. He testified that laryngospasm would be very high on the list of possible causes of death; and in cross-examination felt it was the probable cause of death.
This may well be the case, but the absence of evidence on this point means that we cannot know this to be the cause of death. Although Dr. Jones (and Dr. DeCaen, who accepted Dr. Jones’ opinion as a possibility but who is also not a pathologist) clearly has some relevant experience in this area, he is not a trained and qualified forensic pathologist. Dr. Dowling’s training and extensive expertise is specifically with respect to the issue of cause of death. Where Dr. Adrian Jones’ opinion conflicts with Dr. Dowling’s evidence, I prefer the evidence of Dr. Dowling. Dr. Dowling testified as an expert in forensic pathology. For 18 years he was the Chief Medical Examiner for the province of Alberta. He has a wealth of experience in identifying cause of death.
I find that the cause of death cannot be determined with any certainty, as indicated by Dr. Dowling.
However, Dr. Dowling did testify that some of the more plausible causes that may have led to
Samantha’s death are a seizure, or septic shock. He testified that if seizures are untreated, that would increase the risk of death.
Dr. Dowling testified that the manner of Samantha Martin’s death was natural; in other words, it is clear that she died of natural causes. However, with respect to the cause of death, he explained the
difficulties in drawing a precise conclusion. Although he did not perform the autopsy on Samantha, he reviewed the autopsy report prepared by the pathologist at the University of Alberta Hospital, along with other documentation, and primarily focused on the medical information available. He defined cause of death as a disease or injury that initiates the downhill sequence of events ending in death. He testified that there are really only a couple of things that come to mind as possibilities. From Samantha’s history of absence seizures, he noted that people with seizure disorders can die suddenly and unexpectedly from having a seizure even though it is no different than other seizures they have had previously. It is not known why this happens, but it does occur. He testified it is difficult to say whether Samantha had a seizure, but that it is certainly possible, in which case the cause of death would be seizure disorder due to her underlying Tetrasomy 18p. He testified that this is possible even in the case of absence seizures.
Another possibility, although rare, is that the impacted fecal material in Samantha’s large bowel may
have rubbed away just the inner lining of the bowel, allowing bacteria to seep into the bloodstream,
even though there was no perforation, leading to sepsis and death. Dr. Dowling indicated there is
insufficient information available to determine whether that in fact occurred. That Samantha was in
hospital for a few days after her collapse makes it more difficult to assess as well. These two
possibilities were the ones that Dr. Dowling would attach the greatest weight to; he is not aware of any other possibilities that resulted in Samantha’s death, even though he is aware that others have
attempted to suggest some other causes. Although Dr. Dowling was quite cautious in drawing
conclusions, he was fairly firm in rejecting the hypothesis of Dr. Jones that aspirated stomach contents on the larynx could have caused the death; in Dr. Dowling’s opinion, that is not a cause of sudden death. Aspiration of stomach contents is actually caused by death, rather than the other way around.
Dr. Dowling acknowledged he cannot rule out the possibility completely, but testified it makes no sense in his experience. The absence of evidence of aspiration means it cannot be inferred that this is probably what occurred.
Dr. Dowling testified that he simply did not have enough information to say precisely what happened to Samantha, and therefore in his opinion the cause of death is undetermined.
Dr. Dowling testified that untreated seizures can certainly put a person at greater risk of dying because of their seizure disorder. However, a seizure disorder can result in death even where the individual is being treated and taking appropriate medication. He agreed it was fair to say there would be an increased risk without medication, but stated that it would not be absolute. Dr. Dowling’s evidence about the possibility of seizure disorder playing a role in the cause of death was persuasive in light of his experience and expertise.
Recommendations for the Prevention of Similar deaths:
I find that the manner of death was natural, and that the cause of death may well have been a seizure, but due to the absence of evidence, it is not possible to say that this was the probable cause of death.
However, given the evidence that seizures were likely an issue for Samantha, and in light of the
extensive evidence I have heard, I am of the view that it would be appropriate in this case, to make
certain recommendations to aid in the prevention of other deaths bearing in mind the purpose of the
legislative provisions for the Fatality Inquiries Act clearly includes the attempt to avoid preventable
deaths in the future. The evidence in this case leads me to make the following recommendations:
That Children’s Services should ensure that those caseworkers who work with a foster
child have accurate and up to date information from a reliable medical source about the
child’s disability and in particular, the impact, if any, of the disability on the health,
weight, and fragility of the child. This needs to be well understood in order for the
worker to make informed assessments about how the child is doing in care, especially
in the case of a nonverbal child who cannot communicate concerns with the child’s
worker.
That Children’s Services should look at enhancing current policies to ensure that
children are actually receiving their annual medical checkups as required, including a
diary system so that the issue is flagged and not inadvertently overlooked.
That where a recommendation comes from a reliable source (such as a school
assessment) that a doctor examine the child for a possible medical issue that the child
may be experiencing, that processes are in place to ensure the issue is flagged for
follow up by Children’s Services in an effective and meaningful way, including required
entry by the Children’s Services child care worker or other support staff at Children’s
Services into a diary system.
Ensure that caseworkers for the child have a reasonable case load so that they have
the time they need to be able to adequately document and follow-up on medical needs
of the child.
DATED October 2, 2012 ,
at Edmonton , Alberta.
Original signed
Marilena Carminati
A Judge of the Provincial Court of Alberta


Alberta girl, 13, failed by foster care, inquiry finds

CBC News Posted: Oct 19, 2012 1:05 PM MT Last Updated: Oct 19, 2012 7:36 PM MT
Samantha Martin, 13, died of a heart attack in December 2006, five months after being removed from foster care.
Samantha Martin, 13, died of a heart attack in December 2006, five months after being removed from foster care. (Courtesy of Velvet Martin)
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A disabled 13-year-old girl who died shortly after spending most of her life in foster care was failed by Alberta's foster care system, a fatality inquiry has found.
The report, written by Provincial Court Judge Marilena Carminati, found Samantha Martin was malnourished — weighing only 51 pounds at 12 years of age — and went for prolonged periods without seeing a doctor even though she had a rare genetic abnormality, and should have seen a physician every few months.
"It was totally preventable. She should be with us today," said Samantha's mother Velvet Martin, who received the report this week.
Samantha died in December 2006, five months after she began living full-time with her biological family.
The judge ruled Samantha died of natural causes, likely a seizure, but she pointed out that doctors acknowledge untreated seizures carry a greater risk of death.
While Carminati ruled the cause of death undetermined, she made a number of recommendations to prevent similar deaths in the future.
  • Children's Services should ensure that those case workers who work with a foster child have accurate and up-to-date information from a reliable medical source about the child's disability
  • Children's Services should look at enhancing policies to ensure children are actually receiving their annual medical checkups as required
  • When a recommendation is made by a reliable source (such as a school assessment), a doctor examine the child for possible medical issues
  • Ensure caseworkers for the child have reasonable case load so they have time need to adequately document and follow-up on medical needs of the child
Velvet Martin said she doubts the recommendations will change anything.
"So many cases of families that have been wronged," she said. "There is a lack of follow through, repercussions and deterrence.
"Until we establish some sort of mechansim to hold people accountable, there will be no change," she said.
Shortly after Samantha was born with the chromosomal abnormality called Tetrasomy 18p, her parents put her in foster care upon the advice of workers from the provincial department of Children’s Services.
The family was told Samantha would have access to better medical treatment, the inquiry heard.
But her life in foster care left her undernourished, suffering unexplained bruises and fractures, and only occasional visits with doctors and social workers.
School staff raised concerns with Alberta Children's Services over Samantha's frequent injuries, the meager contents of Samantha's lunches fractures and her seizures.
A pediatrician testified at the hearing that he ususally sees children with Samantha's condition every three months and noted her medical file was unusually thin.
In fact, her medical records show a gap of three years between doctor visits.
Samantha also went long periods of time between visits with a social worker. Samantha's social worker was supposed to meet with the girl every three months, but documents show gaps between visits of up to 14 months.
The social worker testified there were two visits in that period, but she never found the time to complete her paperwork.
At the hearing, the same social worker testified "she would never have been able to find a placement for Samantha that would have been equal to — let alone better than — the quality of care she was receiving in the foster home."

Alberta government releases public inquiry in death of Samantha Martin

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By: Staff Metro Edmonton Published on Fri Nov 02 2012
The results of a fatality inquiry into the death of a 13-year-old Alberta girl were released by the province Friday.
Samantha Martin died in December 2006 in Edmonton's Stollery Children's Hospital. She had suffered from a rare genetic disease called Tetrasomy 18p, which lead to several symptoms and developmental delays.
Martin and had lived with a foster family for a large part of her life and at the time of her death, was living with her biological parents.
On Nov. 29, 2006, she came home from school and was vomiting and experiencing diarrhea. Later in the evening she was taken to hospital, and passed away on Dec. 3 when the decision was made to remove her from life support.
Martin's biological mother Velvet Martin was critical of government for not following up on issues that arose with the foster family. Velvet was successful in establishingSamantha's Law, an amendment to the Alberta Family Support for Children with Disabilities Act in December 2009, which states "The Family Support for Children with Disabilities Program to have separate legislation from that of child protection services."
A fatality inquiry determined that Martin's cause of death remains undetermined, but the manner of death was natural.
The recommendations from the report are as follows:
  • That Children’s Services should ensure that those caseworkers who work with a foster child have accurate and up to date information from a reliable medical source about the child’s disability and in particular, the impact, if any, of the disability on the health, weight, and fragility of the child. This needs to be well understood in order for the worker to make informed assessments about how the child is doing in care, especially in the case of a nonverbal child who cannot communicate concerns with the child’s worker.
  • That Children’s Services should look at enhancing current policies to ensure that children are actually receiving their annual medical checkups as required, including a diary system so that the issue is flagged and not inadvertently overlooked.
  • That where a recommendation comes from a reliable source (such as a school assessment) that a doctor examine the child for a possible medical issue that the child may be experiencing, that processes are in place to ensure the issue is flagged for follow up by Children’s Services in an effective and meaningful way, including required entry by the Children’s Services child care worker or other support staff at Children’s Services into a diary system.
  • Ensure that caseworkers for the child have a reasonable case load so that they have the time they need to be able to adequately document and follow-up on medical needs of the child.
Samantha Martin's death flags foster care failures
Judge recommends improvements to Children's Services
Saturday, Oct 20, 2012 06:00 am
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  • Velvet Martin of St. Albert holds a portrait of her daughter Samantha who died in 2006 of heart failure after being in foster care.
  • Velvet Martin of St. Albert holds a portrait of her daughter Samantha who died in 2006 of heart failure after being in foster care.
  • FILE PHOTO/St. Albert Gazette
Velvet Martin has long sought answers in the death of her 13-year-old daughter.
Samantha Lauren Martin spent the bulk of her life in a Morinville foster home, from the time she was seven weeks old until shortly after her 13th birthday. She then returned to live with her biological family.
Six months later on Nov. 29, Samantha became ill and died at the Stollery Children’s Hospital Dec. 3, 2006 after her parents removed life support.
Martin accepts Samantha died of cardiac arrest, but said it was the result of her neglect in foster care.
“We wanted to expose the deficits that are transpiring that are leading to the casualties of these children,” she said. “I didn’t want Samantha to just be another child that lived and breathed and died and was never recognized.”
The final report, dated Oct. 2, will be publicly released by Alberta Justice on Nov. 2.
In it, Judge Marilena Carminati determined the manner of death was natural, but was unable to determine a cause of death.
“The cause of death may well have been a seizure, but due to the absence of evidence, it is not possible to say that this was the probable cause of death,” she said.
The report says roughly 21 per cent of children with Samantha’s condition, Tetrasomy 18p, a rare genetic condition that leads to various developmental delays, have seizures.
Four basic recommendations were made, all of which are aimed at Children’s Services.
These include ensuring caseworkers have a “reasonable” case load and have accurate and up-to-date medical information about the foster child, with awareness of any impact health conditions could have on weight or fragility.
She also recommended Children’s Services improve policies to make sure children receive annual medical checkups and said the agency should follow up on medical complaints submitted by reliable sources, like school staff.
“What the judge is really recommending is that employees follow their own policy,” Martin said. “It’s very sad that we’ve gone through this process just to find that you should be doing your job.”

Face time

Samantha’s parents put her into foster care shortly after birth, as they believed she would have better access to medical attention.
The family became increasingly involved in her life, starting when she was three years old. The Martins became Samantha’s part-time guardians in 2001 and were set to take over full-time guardianship in December 2006.
Samantha’s life in foster care was riddled with red flags, many of which went undetected by her caseworkers.
Samantha’s caseworker from 1998 to 2005 was required to have at least one in-person visit every three months. There was a 14-month gap between July 2001 and September 2002 where no visit took place.
She testified that her caseload made it difficult to update paperwork and said two meetings were not documented.
Reports show the previous caseworker only met with Samantha three times over a 26-month period. The last caseworker, who took over in September 2005 did not visit Samantha.
The longtime caseworker said she thought Samantha was visiting her doctor regularly.
Her pediatrician testified he would normally see children with similar medical conditions to Samantha’s every three months. He only saw her four times between 2000 and 2004.

Foster care concerns

According to the report, school staff raised concerns about various bruises and fractures, increasing in frequency since December 2005. Samantha’s condition made her largely non-verbal, so she was not able to explain her injuries.
There was also concern as to the contents of Samantha’s lunch compared to the “larger more balanced” lunches given to the foster parents’ biological son.
When school officials raised this problem with the foster mother, she instructed staff to “fill Samantha up with water.” At this time, Samantha weighed just 51 pounds.
Her doctor testified her low weight was not related to Tetrasomy 18p and was instead the result of low caloric intake.
A specialized investigator with Children’s Services became involved in the case at the beginning of 2006, but determined an investigation was not required.
Just one month after moving in with the Martins full time, Samantha’s weight increased by 11 pounds.
Another apparent oversight relates to seizures, which were reported to Children’s Services by school staff.
Her long time caseworker starred a note reading “E.E.G. to rule out seizure disorder” in 2002, but did not follow up. This concern was not shared with the foster mother or Samantha’s pediatrician because the caseworker said she thought they were already aware of the problem.
A doctor testifying at the inquiry said untreated seizures can lead to greater risk of death.
Samantha’s name was originally protected under a publication ban due to her status as a foster child, however, her mother fought to have the ban revoked.
Martin said she would like to see publication bans lifted to expose conditions leading to death in foster homes. She said she intends to seek criminal charges.
“What I want to see is closure of the home so that no other children die and that the caseworker be removed from her position,” she said. “I don’t want anyone else to suffer the loss that we have.”






October 24, 2012 2:42 am

New system designed to better care for foster children

By ELISE STOLTE EDMONTON JOURNAL
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EDMONTON – Alberta’s foster care caseworkers are experimenting with a new information management system that should help prevent lapses in care similar to those identified in a recent fatality inquiry.
Judge Marilena Carminati could not identify the cause of 13-year-old Samantha Martin’s death in 2006, but her report highlighted a series of missed medical appointments and a lack of understanding of Samantha’s underlying disability.
The medically fragile child died five months after returning to live with her biological parents.
The new $34-million upgrade allows caseworkers to better share information among team members, especially about the extended family members available to help with care and medical appointments. It also alerts caseworkers to upcoming deadlines in each file, such as the point at which the province should consider applications for a permanent guardianship order, ministry spokeswoman Roxanne Dube Coelho said.
Caseworkers started testing the new system in 2011; the whole province should be using it by next April.
In her fatality report, Carminati recommended the government develop better methods of tracking visits and medical appointments.
In Samantha’s case, a caseworker was supposed to visit every three months but Child and Family Service records show gaps of up to 14 months. Her pediatrician testified he would normally see children with her genetic disorder every three months, but he saw her, at best, once a year.
Human Services Minister Dave Hancock said the government is hiring more supervisors to help teams of three or four caseworkers. “The key is to say, what can we learn from this. What can we do better,” he said Tuesday.
NDP critic Rachel Notley said the problems identified in the fatality inquiry won’t be solved just by better tracking. The real problem is a continuing lack of resources to help foster children with disabilities.
Samantha couldn’t speak, but started to learn a few words after she returned to her biological parents. “I’d like to hear how much time she spent with a speech pathologist,” Notley said. “I’d like to hear about the special-needs programming she was in to maximize outcomes. It that was a child that wasn’t in care, they would have a raft of experts working with them to maximize their potential.
“This is what I see so often with kids who have special needs who are in foster care.”
Even getting reimbursed for basic medical supplies can be challenging, Notley said.
Families of children with disabilities need money for special dietary needs, medical supplies, transportation to and from therapy appointments, adjustments to the house and diapers, and many costs require separate forms to get reimbursed, she said. “It’s a full time job to get the sign off from the government for the supports they need.”


RESPONSE TO MARTIN FATALITY INQUIRY REPORT December 10, 2012 www.humanservices.alberta.ca The Ministry of Human Services has carefully reviewed and considered the recommendations of the fatality inquiry report released on November 2, 2012, into the December 2006 death of Samantha Martin. The inquiry found this was a medical death due to natural causes, following the child’s return to parental care. Whenever possible, the ministry takes into account reviews of incidents involving children who were recently in care when identifying learnings that could lead to better services for children currently in the system. As we continue to evolve and learn from experience and research, improvements to the child intervention system are always taking place. We have not stood still and waited for this or any other external report to make changes to better serve children and families. Our systems have continuously improved since Samantha came into care in 1993. Today, we support families of children with disabilities differently than we did almost 20 years ago, thanks to staff and our community partners who have led the way in promoting changes over the years. Children with disabilities are no longer served under the child intervention system unless there are concerns for their safety and well-being. The majority of children with disabilities in Alberta and their families are served through the Family Support for Children with Disabilities (FSCD) program, a unique model of support based on pioneering legislation that is recognized as one of the best in Canada. Currently, 98 per cent of children with disabilities involved with FSCD live with their parents and supports are provided to assist the family in meeting their child’s and family’s disability-related needs. Over the past several years, numerous improvements to the child intervention system have been made in response to input from the field, research and reviews. The learnings from systemic reviews and case reviews are incorporated into policy, training and practice, and are shared with staff, caregivers and service delivery partners. Collaborative case planning: Many of the children we serve, including medically-fragile children, require extraordinary services from more than one ministry and in many cases, from various service sectors. The ministry continues to move forward on service delivery approaches that include a focus on collaborative planning and using a cross-disciplinary approach based on the individual needs of the child and family. For example, FSCD and Education’s Program Unit Funding (PUF) program work with families to develop one service and program plan for jointly supporting children with severe disabilities at home and in early childhood education settings. Caseworkers also work closely with agency service providers to provide community-based supports that assist families in addressing concerns to help keep their families together. This approach helps ensure that everyone involved has the same information and understands the plan for services and supports. Caseloads/resources for staff: We continue to monitor staff workloads closely to ensure the needs of families are being met. In addition, we strive to ensure critical front-line positions are filled as soon as possible. There is no set average number for caseloads because each case represents services that are unique to each child. Some cases are more complex because of the needs of the child or the situation of the family. Caseworkers receive initial and ongoing training and support to guide their work with children, youth and families. For example, delegation training for child intervention workers provides an emphasis on assessment to build a better understanding of the greater level of risk and vulnerability of children with special needs. Case management tools such as the new Intervention Services Information System (ISIS) support the ability to enter comprehensive medical information and flag upcoming actions and decision points. Supporting vulnerable Albertans is a top priority for our government. We are committed to continually improving the services we provide for children and families in our province.



Harper must step in over aboriginal child-in-care deaths, says Sherman



Alberta Liberal Leader says deaths violate federal treaty obligations

CBC News Posted: Nov 28, 2013 12:44 PM MT Last Updated: Nov 28, 2013 3:40 PM MT



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Prime Minister Stephen Harper should call a full independent inquiry into the deaths of aboriginal children in care of the Alberta government, says the leader of the province’s Liberal party.


In a letter sent to Harper and the country’s opposition leaders, Raj Sherman calls on the federal government to look into the high rate of deaths among aboriginal children in provincial care.


“The Alberta Government has failed to deliver reasonable care to the First Nations, Métis and Inuit children-in-care in Alberta, and in doing so has placed you in breach of your treaty obligations,” Sherman wrote.


Sherman says that 78 per cent of deaths in the provincial care system have been aboriginal children, who only make up nine per cent of the province’s youth.
Alberta opposition parties have been calling for an inquiry into the number of deaths of children in care following  investigations from the Edmonton Journal and Calgary Herald that found a total of 145 children died while in care since 1999.
During the time, the province only reported 56 of the deaths.
Sherman’s letter notes that children in care is a provincial issue, but that he believes the federal government’s jurisdiction over aboriginal affairs gives them the power to step in and call an inquiry.
“We have the moral obligation and desire to help these children, but the government of Canada has the power to protect these children and we need you to intervene,” Sherman writes.
Sherman has asked for a prompt reply from the prime minister.










Raj Sherman Call for Public Inquiry

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Published by Mariam Ibrahim
Alberta Liberal leader Raj Sherman calls on Prime Minister Stephen Harper to launch a public inquiry into the disproportionate number of deaths of First Nations, Metis and Inuit children-in-care in Alberta. The letter was prompted by a joint Edmonton Journal-Calgary Herald investigation that found 145 children have died in care in Alberta since 1999 - triple the number reported by the province. The investigation also revealed that aboriginal






Alberta NDP leader accuses Redford of desperate bid to divert attention from investigation into child deaths



Jen Gerson | 29/11/13 | Last Updated: 29/11/13 8:14 PM ET
“The government is very much panicking. The opposition has been relentless,” said Brian Mason, the New Democratic Party leader. He suspects it advanced contentious right-to-strike legislation by a week in a desperate bid to divert attention.
Candace Elliott/Edmonton Journal“The government is very much panicking. The opposition has been relentless,” said Brian Mason, the New Democratic Party leader. He suspects it advanced contentious right-to-strike legislation by a week in a desperate bid to divert attention.
The Alberta government found itself on its heels again this week after a newspaper investigation exposed serious flaws in its management of children in care.
After a four-year legal battle, the Edmonton Journal and the Calgary Herald reported 145 children had died in foster care since 1999 — three times the number previously known. Most — 78% — were aboriginal.
Further, the province did not investigate all these deaths and did not adequately track causes. Of those that were investigated, there was no procedure to monitor whether the recommendations of fatality inquiries were implemented.
In fact, Alberta stopped conducting written “special case reviews” in 2009. Instead, there is an internal process that produces no written records accessible under current privacy laws.
The province already has, in practice, the most draconian privacy laws in Canada. Children taken into its custody can never be named, even after they die — not even by their grieving parents, unless they seek leave in court to have the publication ban lifted. Only two have successfully done so. Some parents say they have never received a full explanation of how their children died.
The government is very much panicking
The reporting has been thorough, brilliant and relentless.
Every day this week, the papers ran detailed stories, filled with bereaved parents whose children died after they were taken by the government; pictures of dead children, their faces altered by law; anonymous mothers bitter at their inability to name their children for reporters; parents keeling over graves, hiding their faces.
And each day’s revelations have brought a barrage of questions in the legislature.
“The government is very much panicking. The opposition has been relentless,” said Brian Mason, the New Democratic Party leader.
He suspects it advanced contentious right-to-strike legislation by a week in a desperate bid to divert attention.
“The government is on the defensive and I think a lot of damage has been done.”

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The province has refused repeated requests for a public inquiry. Instead, the human services minister is promising a roundtable discussion in January, a move opposition parties dismiss as a PR gesture.
“This is one of those stories that people feel,” said David Taras, a political analyst at Mount Royal University in Calgary.
“The government is going through its procedures, but nobody is coming up front and addressing the seriousness of this.”
The government has also attempted to deflect blame by casting the reporting as an attack on child-care workers and by criticizing the media.
To be fair, many of those dying in provincial custody did so from natural causes. Further, the 145 deaths are a small fraction of children in foster care — about 9,000 at any given time.
This is one of those stories that people feel
As Mr. Hancock pointed out this week, “There are thousands of successes that happen every day when a child in care is able to go to school after having a good night’s sleep and breakfast in the morning. When a child gets to come home to a caregiver who’s engaged in their activities and supports them to reach their potential.”
His defence evoked derision from talk-show host Roger Kingkade on Newstalk 770.
“It’s tripe,” he said, pointing out it wasn’t the media’s job to report just good news.
As the anger continues to build, Mark Cherrington, an Edmonton-area youth worker, said the newspapers exposed the real problems — chronic underfunding.
This is particularly true on First Nations reserves, which are paid for by Ottawa, rather than Alberta, and receive significantly less support to manage far larger caseloads.
Although aboriginals make up only 9% of Alberta children, they account for about 75% of those in care.
“Right now, it’s getting worse. The cutbacks to group-care facilities is worse. We don’t have the foster homes,” Mr. Cherrington said. “Our population is expanding but our funding is actually decreasing, so the math isn’t adding up.”
He tells of a 15-year-old single mother, who took to sleeping in a graveyard with her child tucked in a carriage.
“It angers me when the government waves its fist in the air and says we have the lowest corporate tax rate in North America, and there’s no provincial sales tax. There’s an outcome of not having revenue and it’s not me, or you, who are the victims. It’s this mother, sleeping in a graveyard.”
National Post
• Email: jgerson@nationalpost.com | Twitter



Restrictive law silences grieving parents

DARCY HENTON AND KAREN KLEISS, CALGARY HERALD AND EDMONTON JOURNAL  01.08.2014
Velvet Martin fought to have the publication ban lifted on the case of her daughter Samantha, who died after being in foster care. She argues many parents want to speak about their children’s cases, but don’t have the knowledge or resources to challenge the ban in court.
Velvet Martin fought to have the publication ban lifted on the case of her daughter Samantha, who died after being in foster care. She argues many parents want to speak about their children’s cases, but don’t have the knowledge or resources to challenge the ban in court.JOHN LUCAS / EDMONTON JOURNAL
Velvet Martin fought to have the publication ban lifted on the case of her daughter Samantha, who died after being in foster care. She argues many parents want to speak about their children’s cases, but don’t have the knowledge or resources to challenge the ban in court.
Velvet Martin fought to have the publication ban lifted on the case of her daughter Samantha, who died after being in foster care. She argues many parents want to speak about their children’s cases, but don’t have the knowledge or resources to challenge the ban in court.JOHN LUCAS / EDMONTON JOURNAL
Human Services Minister Dave Hancock says Alberta’s publication ban on the names of children who have died in care is intended to protect the privacy of families who have already suffered significant tragedy.
Human Services Minister Dave Hancock says Alberta’s publication ban on the names of children who have died in care is intended to protect the privacy of families who have already suffered significant tragedy.SHAUGHN BUTTS / EDMONTON JOURNAL
Jamie Sullivan, who had the publication ban lifted on her daughter Delonna’s case, says parents shouldn’t have to fight in court to speak about their deceased children.
Jamie Sullivan, who had the publication ban lifted on her daughter Delonna’s case, says parents shouldn’t have to fight in court to speak about their deceased children.RYAN JACKSON / EDMONTON JOURNAL

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Alberta’s ban on publicizing the names and photos of children who die in provincial care is one of the most restrictive in the country, robbing grieving families of their ability to raise concerns in public about the deaths and sheltering government officials from scrutiny.
About 10 children die in care in Alberta every year, but because of a law that prevents their names and photographs — and those of parents or guardians — from being publicized, the public is denied the right to know who they are and assess whether their deaths could have been prevented.
Basic information about the 145 children who died in care in Alberta between 1999 and 2013 was only released to the Edmonton Journal and Calgary Herald after a four-year legal battle. Still, we can only tell you the names of two of the 145. That’s because their parents applied in court to have the publication ban lifted — a step all parents must take if they wish to speak out about the deaths of their children.
Velvet Martin, who went through the court process, said the ban is evil and “the nemesis of justice.”
“They have failed the child in the utmost way possible and now they are stealing their identity — the only thing they have left,” said Martin, whose daughter Samantha died after being in care. “It’s bad enough to lose a child, but to have it covered up is just wrong and I won’t stand for it.”
With scant information on child death cases, Albertans are left to trust that the government will investigate and correct any systemic problems, yet often the same people responsible for supervising a case lead the review.
The result of the legislation is a blanket of confidentiality over the child welfare system.
Child welfare agencies won’t talk to the media. Several didn’t respond to repeated requests for information about how they protect children and one, citing the province’s privacy act, referred calls to the Ministry of Human Services.
People who work inside the system are barred from speaking publicly about their experiences; even those who spoke on condition of anonymity were afraid they’d lose their jobs.
Government officials argue the ban is necessary to protect the privacy of children and their families; in some cases, a child who dies might have siblings who are also in government care. Children in care are some of the province’s most vulnerable citizens, and provincial authorities feel strongly about trying to protect them.
“I think there is always a balance of values that you have to take into account,” said Human Services Minister Dave Hancock. “One of the values obviously is an open and transparent process so that people can know and understand what is happening and know that things are being handled in an appropriate fashion. The other value is you don’t want to intrude in the personal lives of families any more than necessary, particularly in circumstances like that where they have already suffered significant tragedy.”
Human Services Minister Dave Hancock says Alberta’s publication ban on the names of children who have died in care is intended to protect the privacy of families who have already suffered significant tragedy.
Photo: Human Services Minister Dave Hancock says Alberta’s publication ban on the names of children who have died in care is intended to protect the privacy of families who have already suffered significant tragedy. Credit: Shaughn Butts, Edmonton Journal.
____
In a press conference on Wednesday, in response to the Journal-Herald investigation, Hancock said that the issue of where that line should be drawn will be discussed at a roundtable of MLAs and experts scheduled for January. Hancock announced the roundtable on Tuesday.
The Alberta College of Social Workers supports the principle of the ban for the benefit of the family and any siblings.
“It could cause some definite hardship for the family,” said spokeswoman Lori Sigurdson. “They could be ostracized in the community. It could be a shame thing. Their relationship with the ministry and the worker who is working with them could become antagonistic or more difficult because they feel they have betrayed them.”
Hancock said the bodies that review deaths — including the child and youth advocate, the quality assurance council and the fatality inquiry review board — provide the public with appropriate access to information. He said it’s “not necessarily useful to publish a name and face just for the prurient interest of the opposition or others.”
However, in an interview this month, Hancock admitted he didn’t realize the law went so far as to prohibit parents from talking about their children and releasing their names to the media, and said he would look into it.
“I think families for the most part need to be able to heal and need to have the discussions that they need to heal,” he said.
That’s the argument made by the family of a 21-month-old aboriginal baby who died in a foster home in 2010.
“It is ridiculous. We want to tell our story and we can’t,” the girl’s aunt said. “We’re suffering in silence here.”
A Morinville foster mother has been charged with second-degree murder, but the case has not yet gone to trial. It could be years before the facts of the case and what went wrong are revealed — if ever.
Choking back tears, the aunt said problems with the system must be scrutinized if similar deaths are to be avoided. “Every couple of years, another child is dying in care, and it is usually a native kid,” she said.
Martin, the mother who had the ban lifted on her daughter’s name, said almost every family she has met wants to speak out, but they often don’t know their rights and can’t afford to seek legal advice.
“A lot of people don’t have the fortitude, they don’t have the education, the ability, to come forward,” said Martin, a spokeswoman for a national advocacy group called Protecting Canadian Children.
In her case, she was able to lobby for a fatality inquiry. During that process, she found out that while Samantha’s caseworker had assured her that the girl — who had a number of medical conditions — was getting exceptional care, the caseworker hadn’t seen her for 14 months, nor had she been examined by a doctor in three years.
“I was naive and under the impression that children’s services was doing an internal investigation and were actually going to do something other than cover their ass,” she said. “It was a hard lesson for me.”
Like Martin, Jamie Sullivan went to court to lift the ban on her daughter Delonna’s name — but she’s angry she had to. “If you want to arrest me for talking about my daughter, then arrest me,” she said. “You can’t take anything more from me than you have already. ... And I’m not going to have somebody telling me I can’t show her picture. That’s just not right.”
Jamie Sullivan, who had the publication ban lifted on her daughter Delonna’s case, says parents shouldn’t have to fight in court to speak about their deceased children.
Photo: Jamie Sullivan, who had the publication ban lifted on her daughter Delonna’s case, says parents shouldn’t have to fight in court to speak about their deceased children. Credit: Ryan Jackson, Edmonton Journal.
____
The publication ban law is part of Alberta’s Child, Youth and Family Enhancement Act. It stipulates that “no person shall publish the name or a photograph of a child or of the child’s parent or guardian in a manner that reveals that the child is receiving or has received intervention services.” The penalty is a maximum $10,000 fine or up to six months in jail.
Prior to legislative changes in 2004, the ban didn’t exist. A 13-member task force, chaired by Calgary MLA Harvey Cenaiko and made up entirely of Conservative MLAs and child welfare officials, had recommended the change to government. Cenaiko told MLAs the new provisions were drafted to align with the Freedom of Information and Protection of Privacy Act. No mention was made that the ban remained in place after a child died.
Provincial privacy commissioner Jill Clayton, who wasn’t in office when the law was amended, said she can’t find any record of the government consulting the office for advice or guidance on the issue.
Across Canada, most provinces ban the publication of names of children who are in care or receiving services from the government, but lift the ban or decline to enforce it when one of those children die. Only Nova Scotia, New Brunswick and Quebec have bans similar to Alberta’s, and officials say Quebec currently does not enforce the ban when a child dies.
But in Alberta, despite the minister’s promise to review the ban, the government continues to enforce it.
This month, Alberta’s children services director refused a request from the Journal and Herald to lift the ban on the name of a Samson Cree baby, opposing an application that was supported with affidavits from both the child’s parents.
Being able to publish the names, photographs and personal stories of children who die in care are large factors in bringing about change, experts say. If parents are muzzled, there is no one else to speak for the children, said Robert Fellmeth, executive director of the Children’s Advocacy Institute in the U.S.
“These children have no lobby,” said Fellmouth, a professor of public interest law at the University of San Diego. “They have no campaign contributions. They don’t vote. Their sole asset is democracy, and public sympathy and concern, and disclosure. That’s the sole political card they have.”
Many laws to protect children are named after child victims, he noted. The Amber Alert system was named for Amber Hagerman, a nine-year-old abducted and murdered in Arlington, Texas, in 1996, while Chelsea’s Law in California, which increases penalties and monitoring of sexual offenders, was named after 17-year-old rape-murder victim Chelsea King.
In Canada, there’s the Jordan Principle that stipulates that care be provided for children when they need it and decisions about who is responsible for paying for it be made later. It is named after a five-year-old Manitoba Cree child named Jordan River Anderson, who died in hospital while federal and provincial authorities bickered over who was responsible for his home care.
And in other provinces, the deaths of children in care make headlines. In Manitoba, a public inquiry has put the 2005 death of five-year-old Phoenix Sinclair under the microscope; in Saskatchewan, RCMP are investigating the alleged 2013 murder of six-year-old Lee Bonneau by another child under the age of 12; and in Ontario, an inquiry has been probing the case of five-year-old Jeffrey Baldwin, who died in 2002 after years of mistreatment.
By comparison, in Alberta, when the child and youth advocate writes reports about flaws in the system, he has to make up names for the children. In July, he released “Remembering Brian,” and just last week he issued “Kamil: An Immigrant Youth’s Struggle.” Both are pseudonyms.
Even when a death of a child in care is examined at a fatality inquiry in Alberta, the children and parents are identified only by initials. Provincial court Judge Leonard Mandamin balked at this practice in an August 2007 fatality inquiry report into the suicide of a 16-year-old Tsuu T’ina boy. “The use of initials dehumanizes the tragic death of this young person,” he wrote.
University of Manitoba professor Arthur Schafer, director of the Centre for Professional and Applied Ethics, wonders who the publication law is designed to protect.
“My overarching concern is that privacy is being used as a smokescreen to conceal potential wrongdoing and to prevent the public from getting an accurate picture of problems that may turn out to be systemic,” he said. “Privacy considerations are important, but they aren’t absolute.”
dhenton@calgaryherald.com
kkleiss@edmontonjournal.com
Publication bans by province
British Columbia: The name and photo of a child who dies in care can be published provided information comes from family or other sources.
Alberta: It is illegal to publish names or photos of children who die in care without a court order lifting the ban.
Saskatchewan: The name and photo of a child who dies in care can be published provided information comes from family.
Manitoba: The name and photo of a child who dies in care can be published provided information comes from family.
Ontario: The name and photo of a child who dies in care can be published without restriction.
Quebec: It is illegal to publish the name and photo of a child who dies in care, but the law is not enforced.
New Brunswick: It is illegal to publish the name of a child who dies in care.
Nova Scotia: It is illegal to publish the name of a child who dies in care.
Prince Edward Island: The name and photo of a child who dies in care can be published.
Newfoundland and Labrador: The name and photo of a child who dies in care can be published if information comes from family or other sources.
http://www.cbc.ca/news/canada/edmonton/parents-can-now-name-alberta-children-who-died-in-care-1.2716816

Parents can now name Alberta children who died in care

Bill 11 approved, lifting automatic publication ban on children who died in provincial care

CBC News Posted: Jul 24, 2014 8:50 AM MT Last Updated: Jul 24, 2014 6:45 PM MT
Kyleigh Tiara Crier hanged herself in the closet of her Edmonton group home. CBC News can now publish her name and photo after the Alberta cabinet approved Bill 11, which lifts the automatic publication ban on children "who have come to the attention" of the director of children services.
Kyleigh Tiara Crier hanged herself in the closet of her Edmonton group home. CBC News can now publish her name and photo after the Alberta cabinet approved Bill 11, which lifts the automatic publication ban on children "who have come to the attention" of the director of children services. (Supplied via Facebook)




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Kyleigh Tiara Crier hanged herself in the closet of her Edmonton group home in April after changing her Facebook cover page to a black and white image of a casket.
“Now, everyone loves me,” the caption read.
CBC News reported on the death of the 15-year-old but could not give her name or publish her picture under Alberta law, despite the wishes of her mother, Crystal.
“There’s a lot of kids who died in care and nobody knows about” it, Crystal Crier said.
Now, for the first time, CBC News can show the picture and reveal the name of the teen who struggled with depression, suicidal thoughts and addictions.

Publication ban lifted

On Wednesday, the Alberta cabinet approved Bill 11, which lifts the automatic publication ban on children “who have come to the attention” of the director of children services.
It means that any of these children can now be identified with the consent of their parents.
"When a child in our province dies and that family says, 'I want to scream at the top of the roof top about an injustice that has happened', they have that right," Human Services Minister Manmeet Bhullar told CBC News. "I want our children in care to have that same right."
Under the old Child, Youth and Family Enhancement Act, parents had to go to court for the right to speak about their children who died in foster or government care.
They can still keep their children’s name confidential but they have to ask a judge for a publication ban.
"Our intention in this is to empower families and those closest to children," Bhullar said.

'Stand behind a face, and not a shadow'

Bill 11 Navaeh Michaud
Navaeh Michaud was eight-years-old when she died of a drug overdose while in provincial care. Her mother named her Navaeh, which is heaven spelled backwards, because "she was my little piece of heaven." (CBC News)
Navaeh Michaud was eight-years-old when she died of a drug overdose while in provincial care. An autopsy report said the young girl's medication was not locked in a drug cabinet as it was supposed to be and concluded she died of a drug overdose.
Her mother, Desiree Michaud, has been fighting to have her name and her daughter Navaeh's published. Having both names made public is a moment she has long been waiting for.
"You have no idea what a relief that is," she said. "To know that people can now stand behind a face, and not a shadow.
"I've heard that a lot of families have gone through what I've gone through. I hope that fighting as hard as I have so far has given them strength to come forward themselves about their little ones who have maybe been abused, beaten or had a suspicious death."
Crier's mother Crystal called the approval of Bill 11 a "burden off my shoulders."
"I cried happy tears," she said. "I didn't cry because I was sad. I was happy."

Long journey ahead

Michaud said it's still not easy to speak about her daughter in the past tense.
Bill 11 desiree michaud
Desiree Michaud has been fighting to have both her and her daughter's names and photos published. She said having the automatic publication ban lifted brought her "relief." (CBC News)
"She was the most warmhearted, kind, loving fun child. She just brought light to everybody's life."
Navaeh's name is heaven spelled backwards, because Michaud said "she was my little piece of heaven."
"I want people to know who this little girl was," Michaud said. "See her face and that beautiful little smile. See what somebody or something decided to take away from this world."
With files from CBC's Janice Johnston and Briar Stewart

http://humanservices.alberta.ca/documents/Publication-Ban-Fact-Sheet.pdf


The need to protect the privacy of vulnerable
people is balanced with our responsibility to be
open and accountable about the work we do
and how we do it.


To help ensure the privacy of children and their
parents or guardians, the Child, Youth and Family
Enhancement Act and the Protection of Sexually
Exploited Children Act prohibit the publication of
specific identifying information in a manner that
reveals the child’s involvement with the child
intervention system.


What does the publication ban cover?
The Child, Youth and Family Enhancement Act,
section 126.2(1), prohibits the publication of the
name and photograph of a child, or the child’s
parent or guardian, if the publication reveals that
the child is receiving, or has received, intervention
services.


The Act contains a definition of intervention
services. These services include, but are not limited
to, foster care, secure services, and enhancement
services provided to a family in their home. For
further clarification on what constitutes an
intervention service, see s.1(1)(m.1) of the Child,
Youth and Family Enhancement Act.


The Protection of Sexually Exploited Children Act,
section 6.3(1), includes a similar publication ban.
Under this legislation, help is available to children
who are sexually exploited through prostitution.


Are there any exceptions to the publication
ban?
There are circumstances in which the name or
photograph of a child, parent or guardian can be
published:
The Director of Child, Youth and Family
Enhancement believes it is in the best interests
of the child or necessary for the proper
administration of justice and consents to the
publication.
The child is 16 years of age or older and
consents to the publication of his or her
information. (Note: the child cannot consent to
publication of the parent or guardian’s
information.)


The court grants permission, upon application
by an interested party, to publish the name or
photograph of the child or parent or guardian on
the basis that publication is in the child’s best
interests or in the public interest.
The publication ban provisions do not prevent a
parent from discussing their child’s particular
situation with the media; however, the consent of
the Director, or an order of the Court, is needed to
publish the name and/or photograph of their child in
a manner that reveals the child is receiving or has
received intervention services.
What is the penalty for breaching the
publication ban?
The penalty for breaching the publication ban is a
fine of up to $10,000, or in default of payment,
imprisonment for a term of up to 6 months.
If you are unclear about whether a story breaches
the publication ban, you are encouraged to seek
legal advice.
What has changed from the direction in the
previous publication ban?
Previously, the publication ban prohibited
publication of any information that could serve to
identify a child or the child’s guardian as having
involvement at any time with the child intervention
system.
The legislation now states specifically what
information is captured by the ban: the name
and/or photograph of the child or the child’s
parent or guardian, both of which cannot be
published.
The legislation now clarifies which children are
protected by the ban: a child who is receiving,
or has received, intervention services.
Interested parties, such as the media, may now
apply to the court for permission to publish
protected information on the basis that
publication is in the child’s best interests or the
public interest.
A child 16 or older may consent to the
publication of his or her information. Previously
the age was 18.
PUBLICATION BAN



A child in care is missing.
The name and/or photograph of child can be published as long as the child is not described as receiving child
intervention services (i.e. a foster child or child in care).
The child’s residence cannot be referenced as “foster home” if the name and/or photograph of the child are used.
Publication of a child’s or parent/guardian’s identity is only a breach when there is reference that the child is
receiving, or has received, child intervention services.
If it is important to the case that the child be identified as a foster child, consent must be obtained by the Director
of Child, Youth and Family Enhancement prior to the name and/or photograph being published.


A youth in care is charged with a crime.
Youth under the age of 18 charged with a crime cannot be identified under the Young Offender’s Act.
The youth may be referenced as receiving or having received child intervention services if their name and/or
photograph, or the name and/or photograph of their parent/guardian, are not published.


A child in care is involved in an accident that is being publicly reported.
The name and/or photograph of child can be published as long as the child is not identified as a foster child or
child in care.
Other people involved in the accident cannot be referenced as “foster parent, foster sibling” if the name and/or
photograph of the child are used.


A foster parent is charged with a crime.
The publication ban does not apply to caregivers who are not the parents/guardians of a child in care.
The name and/or photograph of the foster parent may be published along with references to being a foster parent.


A family receiving child intervention services is profiled for their successful work at keeping their family
together.
The name and/or photograph of the parents or children cannot be published, however it is possible for the family
to be interviewed and photographed in a non-identifying way (i.e. use pseudonyms or first names only).
A child 16 or older may consent to the publication of his or her information, however the child cannot consent to
publication of the parent/guardian’s information.


A family wants to share their concerns about their involvement with child intervention services publicly.
The Act does not prevent a non-custodial parent from discussing their child’s particular situation publicly, but the
name and/or photograph of the child receiving child intervention services or their parent/guardian’s name and/or
photograph cannot be published.
Publication of a child’s or parent/guardian’s identity is only a breach when there is reference that the child is
receiving, or has received, child intervention services.


A community program serving children and/or youth in care is being profiled publicly.
If the program is described in a manner that does not identify it as providing services to children and/or youth in
care or receiving child intervention services, names and/or photographs of the children can be used.
The name and/or photograph of children receiving services from the program cannot be published if the program
is described as providing services to children and/or youth in care.


A youth in care is graduating high school.
A youth aged 16 or older can consent to have their name and/or photograph published along with information
about the youth receiving child intervention services (i.e. referenced as a foster child or being in care).


A child receiving or having formerly received child intervention services has won a public award.
The name and/or photograph of child can be published as long as the child is not identified as a foster child, child in
care or having received child intervention services.


January 2014


http://pa-pa.ca/Alberta.html


Unreported Deaths of Albertan Foster Children

Introduction

Each province in Canada has its own child protection agency. Age of protection ranges from 16 to 19. While most agencies are run directly under a provincial government ministry, some are operated by "non-profit" organizations (such as the children's aid society or CAS in Ontario). They are all fully empowered by a provincial statue to remove children from their parents at will.
Child protection agencies have a different name in different jurisdiction. Some are more suggestive than others of the alleged nature of child protection. In Alberta, child protection falls into the mandate of the Ministry of Human Services (hereinafter known as the MHS), formerly known as the Ministry of Children and Youth Services. MHS is governed by the Child, Youth and Family Enhancement Act (CYFEA) that empowers bureaucrats to remove children from their parents based on their opinion. Unlike many other Canadian provinces, Alberta has a provincial law banning publication of names, photos and other identifiable information of children who die in government care. The Alberta government is effectively shielded from scrutiny, grieving parents are silenced and the media does not have much to report. Such restrictive law works very well for the child protection industry (hereinafter known as the industry) until it backfired in November 2013.



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