VICTORIA - There's some new appalling detail on almost every page of the report into why a little boy was left for months in the care of the man who beat his 19-month-old sister to death.
The government finally released Child and Youth Officer Jane Morley's report Friday, after sitting on it for three weeks. The report paints a terrible picture of failure, of a system snarled in rigid bureaucracy and plagued by paralysing secrecy, suspicion and indecision.
Ministry of children and families staff were keeping secrets from Usma, the First Nations' agency delivering child protection services to the family. Usma workers were keeping, it turned out, the same secrets from ministry staff.
Pleas for help and direction from front-line workers were ignored by senior ministry staff.
Even as chaos and confusion mounted, no one at the top levels of the ministry stepped in, called people together and sorted things out,
And all the while the Coroners Service, responsible for child death reviews, was refusing to provide critical information - including the details of the terrible injuries that killed Sherry Charlie - to the people charged with protecting her three-year-old brother Jamie and the other children in the Port Alberni home.
It's a grim recitation, made bearable only because the children weren't physically harmed.
Sherry Charlie, who had been placed in the care of family members by Usma on behalf of the ministry, was beaten to death Sept. 4. Within five days preliminary autopsy results made it clear to the coroner and police that she hadn't died from a fall down a few stairs, as the family claimed. She had head and abdominal trauma, a lacerated liver, internal bleeding and other injuries.
But neither coroner nor police shared that information with the ministry or Usma for almost two months.
Some scenes in the report stand out, moments that can convey the bizarre way this case was handled. By late October, eight weeks after the killing, the coroner had told ministry staff - vaguely - that Sherry's death hadn't been caused by a fall down stairs. But the coroner had insisted the information be kept secret.
Usma was about to extend Jamie's placement in the home. A senior ministry official was concerned enough to call the Usma supervisor and ask if she was sure that was the right decision. The puzzled Usma worker asked if the ministry knew something that she didn't.
Instead of answering, the ministry manager allowed a silent pause. She thought that was a good way to hint at problems; the Usma worker thought she was acknowledging there were no concerns. It was a ludicrous way to deal with a child in danger.
What also stands out is the failure of the Coroners Service to discharge - or even grasp - its responsibilities. It took four months for the coroner's service to produce an autopsy report on Sherry's death, which confirmed the original findings. It took another two months of effort to get the coroner to provide the report to the ministry.
This despite a legal requirement that coroners, like others, immediately report to the ministry any facts that raise questions about a child's safety.
It's grim. The Coroners Service priority appeared to be the police case, not children's safety.
Worse, Morley notes that the coroner involved and the Coroners Service both tried to argue that she shouldn't be allowed to comment or report on the possibility that the service had made mistake, broken laws or make any comments that "reflect adversely on the Coroner's competence." It's an incredible attempt to deny public accountability and hide from independent scrutiny.
The other alarming element to all this is that the facts are only coming out now, more than four years after all this happened.
And for much of that time the government has insisted that there was no need for an investigation, that the case had been properly handled and the Coroners Service was handling its responsibilities effectively.
Morley's report shows that none of those claims were true.
Footnote: The report includes on recommendation which urges the government to create a "system of multi-agency child death teams" to investigate when a child dies unexpectedly in the home of a caregiver and other children remain in the home. If the system had been in place, Morley says, police, coroner, the ministry and Usma could have worked together quickly and effectively.