Advocate for Children and Youth
January 12, 2016

Advocate for Children and Youth Releases Investigative Report �A Tragedy Waiting to Happen�

Statement from Carol A. Chafe, Advocate for Children and Youth:

Good Morning:

I will be giving a prepared statement, after which I will be happy to take questions; however, at this time, it is important to remind you that I will not provide information which violates confidentiality.

On January 14, 2013, I called an investigation into the circumstances surrounding the services provided to three children living in a remote and isolated community in Labrador. The purpose of this investigation was to determine whether the services provided by the Department of Child, Youth and Family Services (DCYFS); the Department of Health and Community Services (DHCS); the Department of Justice; and the Labrador-Grenfell Regional Health Authority (LGRHA) met the needs of these children and whether their right to services was upheld.

The investigative process undertaken in this case was comprehensive and involved the review of case files and documents provided by the four (4) departments and agencies involved. Interviews with professionals and a review of applicable policies, procedures and legislation were also undertaken.

�A Tragedy Waiting to Happen� is a story of three vulnerable children and how government services failed to meet their needs. Over a period of eight (8) years, these children had numerous encounters with many professionals, yet they continued to live in an unacceptable, unsafe environment detrimental to their health, safety and wellbeing. In that eight (8) year period these children received government services; however, continued to live in harmful conditions until 2010, when a fire claimed the lives of (2) of the three (3) children and one adult. I extend my deepest condolences to their families and friends.

The deficiencies identified throughout this investigation reflect the eight (8) year timeframe from 2002 to 2010. Through information gathered during interviews completed in late 2014 of the service providers involved with this case, and through our daily advocacy work, it is evident that these deficiencies still remain today. This report in particular highlights the specific challenges of communities in Labrador, where factors such as environment, workload, and human resources issues, have not permitted the necessary changes to occur.

Issues identified specific to each department and agency investigated are as follows:

Department of Child, Youth and Family Services:

  • Documentation deficiencies;
  • Lack of comprehensive assessment, intervention and followup;
  • Challenges to service provision; and
  • Lack of collaboration, communication and information sharing.

Department of Health and Community Services and Labrador-Grenfell Regional Health Authority:

  • Failure to report child protection concerns;
  • Lack of comprehensive nursing assessment;
  • Inappropriate medication prescribing/dispensing � evident in this case, these children ages 8,4 and 3, had a total of 281 visits to the local community clinic resulting in 101 prescriptions for antibiotics.
  • Lack of supervisory oversight; and
  • Lack of collaboration, communication and information sharing.

Department of Justice and Public Safety and Royal Canadian Mounted Police

  • Failure to report child protection concerns; and
  • Lack of collaboration, communication and information sharing.

There are 10 recommendations resulting from the completion of this investigation; three of which are the joint responsibility of more than one department and agency.

Overall for:

  • Department of Child, Youth and Family Services � Five recommendations
  • Department of Justice and Public Safety � Two recommendations
  • Department of Health and Community Services � Five recommendations
  • Labrador-Grenfell Regional Health Authority � Two recommendations

In keeping with the public release of any report from this Office, my hope is that people will take the time to read this report and see for themselves just what went wrong. I hope it will also help people understand the responsibility we all have to ensure that our most vulnerable, our children and youth, are protected and receive the services they rightfully deserve.

While this is a public report, every effort has been made to ensure that the identities of those involved are kept confidential. I strongly request that members of the public and the media not focus on identifying the specific location of this case or the identity of the people involved. Rather, I ask that you focus on the lessons that can be learned from this tragic story.

I want to take this opportunity to acknowledge those professionals who strive every day to do their best. I want to thank the professionals who answered my questions with such honesty and with a passion for wanting change to improve the system, change that can ultimately prevent future harm.

I will be providing each of you present today with a copy of the report. As well, printed copies are available to the public upon request by contacting our office. The report can also be viewed on our website: www.childandyouthadvocate.nl.ca  external link

Thank you for your time today and I welcome any general questions.

Carol A. Chafe
Advocate for Children and Youth

2016 01 12                             11:10 a.m.