Anyone paying attention - especially people being paid to do just that - could have seen things were going to end badly for the 15-year-old girl with Down's syndrome and her mom.
And things did end badly. The girl spent days alone in a dirty trailer with her mother's decomposing body last fall. She was filthy, emaciated and covered in an angry rash when found - and frightened.
When neighbours came to her rescue, she couldn't hear them. Her hearing aids had stopped working at some point in the past. No one had noticed. She had lived in needless silence.
B.C. Representative for Children and Youth Mary Ellen Turpel-Lafond reported on the case this week. It is grim reading.
The desperate family's downward spiral occurred over years. There was ample evidence of deteriorating conditions for both mother and daughter. For almost four years, the Ministry of Children and Families had been warned the child was being abused and neglected. Investigations were incomplete and inadequate, failing to take the modest steps needed to get at the truth of the family's collapse.
As all this happened, the government was supposed to be providing children with special needs and their families help with assessment, planning and services. That didn't happen either.
Lord knows the child needed support. She was sickly and weak, needed leg braces and hearing aids and glasses. At 15, she had the intellectual functioning of a pre-schooler.
She was also a warm and loving child, lo9ved in turn by her mother.
In a family with money and savvy, she might have fared well.
But her mother was poor. When her car broke down, she had to give up the two jobs she was working. She was on income assistance – a life of poverty - and sometimes collected cans and bottles to get by. She couldn't afford a phone.
And she battled her own issues with illness, physical and mental, and, apparently, with alcohol.
Families of children with special needs are supposed to be getting support to make sure services are there. But the government shuffled responsibility to Community Living BC from the children's ministry in 2005, then decided that was a bad idea and shuffled them back in 2009. Supports were inadequate, caseloads overwhelming and children fell through gaping cracks.
And all children are supposed to be protected from harm by the ministry of children and families. That's impossible, of course. But in this case, the report found, there were complaints about the home and warning signs of obvious risk. At the least, this family needed support; it's likely the child should have been apprehended.
Instead, things got worse and worse.
Turpel-Lafond also found this case was not just an aberration, or the result of individual failures. "Is this a unique circumstance, a cruel anomaly?" she said. "Tragically, it is not."
One of the government workers responsible for supporting the child had a caseload of 200 families. There is simply no way to do the work properly under those conditions.
The government cut off the mother's income assistance in the month of her death, although it knew she was supporting a disabled child, without visiting the home or warning the children's ministry.
In short, the systems that were supposed to protect children and support those with special needs were structured to fail.
Children's Minister Mary McNeil promised action on the report's recommendations. But the public has heard that before. Only three years ago, Turpel-Lafond outlined the problems with supports for children with special needs. Nothing happened.
There's one simple test of the government's commitment. The report called on the government to assess the services, resources and support required for children with special needs, the province's current commitment and the actions that would be taken to close the gap.
Until that's done and released, it would be foolish to accept yet more promises of improvement.
Footnote: The ministry's initial position was that the case did not involve a "serious injury" so it did not have to report it to the representative. An internal ministry review found "all of the required standards were complied with" in its dealings with the family.
Which confirms that the problems are built into the current system.