"The Ministry of Children and Family Development missed opportunities to learn from its mistakes by failing to review a number of infant deaths, B.C.'s independent child advocate says," reports Lindsay Kines in the Times Colonist today.
"Mary Ellen Turpel-Lafond, who examined the deaths of 21 infants for a recent report, noted that the ministry conducted its own internal investigations in just 14 of the cases."
All the deaths should have been reviewed based on the ministry's standards, the representative found. In the 14 deaths that were reviewed, "a number took too long complete, ignored key issues or failed to recommend changes that would fix identified problems."
The representative also said regional directors were reviewing cases in which they were involved - an obvious conflict of interest. Minister Mary Polak agreed and said some changes would be made. But the ministry has been "transforming" itself for years with no clear improvements. Where is the accountability for managers who failed to ensure an effective independent review process?
The article is here.
The representatives report, Fragile Lives, Fragmented Systems, is here.
But the individual case studies from the report tell much of the story.
Here's the second one. (The first one is in the post below.)
Case Example Two
This First Nations child was born into a home with other young children. The family lived in poverty and often relied on relatives, transition housing and motels for accommodation. MCFD became aware that the mother was expecting early in her pregnancy.
The mother had been admitted to hospital after being assaulted by her spouse during her pregnancy. Prior to the infant’s birth, 14 child protection reports had been made to the ministry, primarily about alcohol abuse and domestic violence. Four of these reports were made while the mother was pregnant with this infant; they included concerns about inadequate housing, emotional abuse of the infant’s siblings and substance abuse. One of the reports was investigated and not substantiated. The other three were not investigated. The MCFD file was closed before the infant was born.
According to the MCFD file information, the newborn was assessed at birth by a program in the local hospital that worked in conjunction with the public health unit. The program reportedly assessed newborns for medical as well as social/emotional risk factors. The newborn was assessed by the program as low risk and was discharged from hospital the following day. It does not appear the hospital was aware that the family had no reasonable housing and a history of substance abuse and family violence. It appears this MCFD information was not shared with the hospital following the infant’s birth.
The infant was seen three times by public health nurses from birth to three months of age. At the second visit, the mother reported that the infant had noisy breathing while asleep, which a doctor thought was possibly the result of a floppy epiglottis.
Approximately two months later the mother took the infant to see a doctor because the noisy breathing persisted and a cough had developed. The doctor thought these symptoms were possibly due to an infection and prescribed amoxicillin. At the third visit with the public health nurse, the mother informed the nurse that the infant’s noisy breathing persisted, and she also informed the nurse about the previous visit to the doctor. No follow-up regarding the infant’s breathing was noted on the record of the visit.
The infant died four days after the last visit with the public health nurse. On the evening of the death the infant had been left in the care of adolescent babysitters. There was no crib in the home. The babysitters placed the infant to sleep in a car seat that was on top of a soft mattress. Sometime later the car seat turned over, and the baby was asphyxiated.
The key point is that the child's bleak future was foreseeable and the death could have been avoided. The baby never really had a chance and no one took the small steps that could have made a difference for the children in this messed-up family.
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4 comments:
I was with you up until the moment you make the comment that it is the family that is messed up. The child was seen by how many 'health' professionals before her untimely death? Poverty, addiction and violence are problems connected to colonialism and post-colonial prejudice: they are systemic in origin, but the suffering is personal.
That struck me too Paul. The story's summary line ("messed up family") was right out of the blue, without any facts to corroborate it, and disconnected to anything material in your story.
You do say that there was a "history", presumably (?) as documented in the ministry files, but you provide no evidence that this history was either correct or current, or that it was in any way related to the death of the baby. If this was a current concern, why didn't the ministry staff do/say anything at all about these issues?
From the facts you have presented in this story, this was an accident, one that could occur in any family:
- It's legal and even encouraged that "adolescents" i.e. anyone over the age of 12 years, is thought mature enough to look after children, even babies.
- As for babies sleeping in a car seat on top of a soft mattress, well I see lots of babies sleeping in a car seat that's on any number of surfaces, including a "soft" mattress.
- That the car seat over-turned? That happens. That this baby was asphyxiated? Yes, this can happen in an instant, in what seems like seconds... Like many children who drown when a parent leaves the bathroom... momentarily.
All of the above are not indications of a "messed up" family.
Yet, you write this story as a castigation of the family, particularly the "adolescent" babysitter(s). I believe you owe the family and those young people who were good enough to babysit an infant, a heartfelt apology.
I'd say you missed the mark by a country mile Paul. It isn't a problem of a messed up family. The real target of criticism and castigation should be the ministry and the health "professionals" in this story.
From your reporting of the contents of the Children's Commissioner's report, I deduce the following failings:
- The ministry did not communicate the lack of housing, etc. to the hospital, or the hospital did not take into account the housing problem.
- So, the ministry noted a history of drug abuse, presumably current, you don't say... but did nothing about it, and permitted the baby to be discharged without providing any services to the mother or family.
- The most proactive person here appears to be the baby's mother. She reports her concerns about the baby's health. A doctor offers a couple of theories, and did nothing. The mother persists in voicing her concerns, first to the doctor who offers another theory and penicillin, with no positive results, no follow-up, and the mother appeals yet again to public health nurse to try again to get someone to help her baby. And still, NOTHING is done.
- The public health nurse appears to have taken no meaningful, useful action beyond "visiting" and, of course, taking notes.
You suggest that this is all about the lack of "accountability for managers who failed to ensure an effective independent review". No, that is not the issue you wrote about. What your depiction of this case shows is the utter,complete lack of any meaningful, useful or helpful services that were provided to help treat this baby's illness. Pure and simple. The death of the infant was an accident. A tragic accident.
The real tragedy is this ministry of "children and family development". What an oxymoron that ministry's title is.
Anon and StandUp:
Thanks for the comments. The report, as I posted, says:
"The mother had been admitted to hospital after being assaulted by her spouse during her pregnancy. Prior to the infant’s birth, 14 child protection reports had been made to the ministry, primarily about alcohol abuse and domestic violence. Four of these reports were made while the mother was pregnant with this infant; they included concerns about inadequate housing, emotional abuse of the infant’s siblings and substance abuse."
To me, that's a messed up family. It's not a judgment on whose fault, just a statement of fact.
Paul
Yes, I'd say that's true, those facts would indicate it is a messed up family. I did not read the reports, only your column.
However, your story was ostensibly about the criticisms of the Representative for Children & Youth, and yet, your message seemed to be a castigation of the family, not the ministry or the health professionals it oversees.
The story is about the professionals who are being paid to do a job but are not. Your column veered off the road Paul and ended in the ditch grazing the family, and completely missed the ministry.
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