Inquest into toddler’s death ends with seven recommendations

After four hours of deliberations, recommendations have been made at the coroner's inquest into the death of a three-year-old in foster care.

The little boy died of bronchial pneumonia and influenza in Dec. 17, 2009.

The testimony heard over five days left one of the social workers on the stand in tears and there were graphic photos of the state of the home at the time of the death.

But the seven recommendations made by the six-person jury may leave the ministry of social services wondering how to implement them.

One is as simplistic as more closely monitoring foster families.

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The other six are:

– More thorough checklists of the safety standards in the home including smoke alarms, carbon monoxide detectors, fire hazards, child safety gates and other mechanical items. And that there be more unannounced visits to foster homes by caseworkers.

– That local tenders be used to hire handy men or women to work on the maintenance and other building issues or upkeep of foster families homes. And to run advertisements to help with that process.

– Better supports for foster families in the rural setting and urban areas as well.

– That clear obligations be laid out for caseworkers to report to supervisors every time a concern is raised following a home visit, with clear and concise language used so that supervisors know exactly what is going on in the child's case. And that foster families attend age-appropriate parenting classes.

– That children with special needs be placed in foster families that can adequately meet their special needs and that the foster families they are placed with receive all medical information and history about the child in the care and that they know the action to be taken in the event of an issue.

– For the stipend or maintenance payment made to foster families that are caring for children with special needs be increased.

But all this is little comfort to the boy's grandmother, who also cannot be identified.

“This was a preventable death,” she said, near to tears, reading from a pre-written statement. “One dies so many others can live.”

The Ministry of Social Services wants to spend some time going over the recommendations made. But in a brief statement moments after the inquest ended, Andrea Brittin with Child and Family Services expressed regret.

“We offer our sincere sympathy to the family and friends of this young boy,” she said.

Having only just received the recommendations, there likely won't be further comment until later in the week.

The seven recommendations will be released in full by the Chief Coroner, hopefully on Monday.

Throughout the week, testimony was heard from RCMP who attended to the death and the pathologist. It was determined the boy died from a treatable bacterial infection that started with bronchial pneumonia. With treatment, there was a 90 to 95 per cent chance of survival.

Much was heard about the unsafe, unsanitary and cluttered state of the home. The pathologist found no evidence that linked the living conditions to the boy's death. But coroner Alma Wiebe, in her instructions to the jury, did state that the four woman, two man jury could infer that sanitation and safety spoke to the quality of care the boy was receiving.

It was the second set of directions given to the jury who first came back with a series of recommendations in draft form, but were sent back for revisions. The Coroner's Act requires that the recommendations made be within the law and can actually be implemented by those to which they are directed.

The jury is also required to decide on the manner of death whether it be natural, accidental, suicide, homicide or undetermined. The jury opted for homicide, but in a coroner's inquest, the term does not carry the same definition as homicide within the criminal code. It is defined here as a voluntary act as to cause fear, harm or death.

Social workers who testified at the inquest stated that concerns had been raised about the condition of the home four months before the boy's death, but reactive steps only started a month before it happened. Many agreed the standard of care at the time was not met in this boy's case and that communication between departments could be improved. One manager described the system as compartmentalized, with no one really understanding the work of others within the chain.

The foster family in this case won't be receiving any more foster children, but their three adopted children remain with them.

news@panow.com