Wednesday, June 14, 2017

Edmonton’s medical examiner testified Monday, on the first day of the inquiry, that Nevaeh had more than four times the prescribed level of a sleep aid in her system when she died. “If we as the parents neglected our children and they died, where would we be?” John Knoll said. “In jail. Why do they get special privileges?” “Everyone should be held accountable,” Desiree Knoll said.----------“This has been going on for a lot of years now,” said John Knoll. “So they’ve had lots of opportunities to change the system and make it work.” Desiree Knoll has faith that the findings of the inquiry will help get justice for her daughter, for other children and will hopefully achieve prevention measures. “That’s faith I have to have,” she said.-----



This case raises issues about what sort of medication management system is present in group homes and who is responsible for this case of an overdose?
In a supportive living or long term care facility medications are supposed to be strictly monitored with a pharmacist having oversight of the system.
But who does this work in a group home? The group homes my parents looked at weren't (in our family's opinion) suitable for handling complex care patients.
If this child had complex care needs should she not have been better served in an institution? Why can't we have a complex care facility for children, youth and adults in Alberta? Why can't we repurpose Michener Center for this purpose?
While community integration is the ideal sometimes this is JUST NOT POSSIBLE.
We need complex care places where children like Nevaeh Michaud would have supervised provision of medications so that an overdose would have been unlikely and if it had happened would have resulted in prompt attention to save her life.
This sort of care is no care at all in my opinion.
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http://edmontonjournal.com/news/crime/nevaeh-michauds-parents-react-to-fatality-inquiry

Parents hopeful fatality inquiry will bring justice for child who died in care

Published on: June 14, 2017 | Last Updated: June 14, 2017 5:53 PM MDT
John and Desiree Knoll pose with a picture of their daughter Nevaeh Michaud who died in an Edmonton group home in 2014 on Monday, June 12, 2017. The parents were at Edmonton's Provincial Courts attending the fatality inquiry into their daughter's death from an overdose of a sleep aid while in care.
John and Desiree Knoll pose with a picture of their daughter Nevaeh Michaud who died in an Edmonton group home in 2014 on Monday, June 12, 2017. The parents were at Edmonton's Provincial Courts attending the fatality inquiry into their daughter's death from an overdose of a sleep aid while in care. EDMONTON
In the front row at the fatality inquiry into the death of Nevaeh Michaud, John and Desiree Knoll sat in the provincial courtroom with a family friend, looking at photos of their daughter, taking notes and occasionally tearing up.
Eight-year-old Nevaeh died in 2014 at an Edmonton group home from an overdose of the sleep aid chloral hydrate. Her mother Desiree Knoll said the inquiry was painful, but that she wanted to represent her daughter.
“Memories are being brought up that I didn’t want to have to feel again,” she said on the first day of the inquiry. “However, I do see this going in the right way for Nevaeh.”
The Knolls don’t make excuses for their daughter being in government care. The couple struggled in previous years. Their daughter had severe developmental, behavioural and health-related disabilities.
But they do have questions about what happened once she was in Alberta’s child-welfare system. Edmonton’s medical examiner testified Monday, on the first day of the inquiry, that Nevaeh had more than four times the prescribed level of a sleep aid in her system when she died.
“If we as the parents neglected our children and they died, where would we be?” John Knoll said. “In jail. Why do they get special privileges?”
“Everyone should be held accountable,” Desiree Knoll said.
The province’s child-welfare system has been under intense scrutiny for years. Alberta’s human services minister revealed in January 2014 — the month that Nevaeh died — that 741 children with a connection to the system had died in the previous 14 years. A government-appointed panel is now reviewing the system in the wake of the death of another child, Serenity. Her September 2014 death raised serious questions about failures in the system and the subsequent investigation.
Alberta’s child and youth advocate Del Graff previously investigated Nevaeh’s case in 2015, publishing a report that used a pseudonym. Graff called on the province to ensure better medication management and identify more homes equipped to support children with severe developmental disabilities.
Her parents say change is critical to prevent future in-care deaths.
“This has been going on for a lot of years now,” said John Knoll. “So they’ve had lots of opportunities to change the system and make it work.”
Desiree Knoll has faith that the findings of the inquiry will help get justice for her daughter, for other children and will hopefully achieve prevention measures.
“That’s faith I have to have,” she said.
The fatality inquiry continues Thursday.



Julie Ali · 

While the fatality inquiry is useful in providing the public with some information about the deaths of these children in care they provide no accountability. In other words, the judge may or may not make recommendations. Government has no requirement to adopt anything that the judge recommends. Then there is the matter of holding anyone accountable. Judges can't lay any blame. So really even if there were deficiencies in the work performance of workers involved or in the group home's oversight no one is going to receive any penalties. It's a sad state of affairs.

The parents in this case would have received more scrutiny if this over dose had happened at home. But when the government is the public parent of these children there is no sort of penalty, no blame laid and no change. Every case of a child who dies is an opportunity for the system to implement recommendations and avoid repeats of these preventable errors and outright failures in performance but unfortunately I don't see any sort of systematic effort made to implement the "learnings" from adverse events and fatalities.

While the parents of this child have the faith in the system, I no longer have this faith and I encourage citizens to realize that we have no oversight of vulnerable citizens anywhere in the system and we're the oversight required. Unfortunately for children in the care of the GOA they may not have access to family advocates and are doubly at risk. At least the seniors and handicapped citizens who are in the continuing care system may have access to family advocates even if they too, are hobbled by retribution such as banning, evictions and lawsuits.
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