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By Canadian Press

20 Recommendations

Judge makes long list of recommendations after girl’s death while in care

Jan 6, 2023 | 9:27 AM

Editor’s note: This story contains graphic details and descriptions.

EDMONTON – An Alberta judge has made 20 recommendations from a fatality inquiry into the 2014 death of a young girl in care.

The Indigenous girl known as Serenity was four when she suffered a serious brain injury after falling from a tire swing at her guardians’ home in Maskwacis, south of Edmonton. She was on life support for 10 days before she died.

At 6 1/2 months old she was taken from her mother by children’s services after the woman was assaulted by Serenity’s father.

Serenity and two older siblings were placed with their great aunt and uncle and the couple’s teen daughters in a kinship care arrangement in 2013.

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The guardians were charged in 2017 with failing to provide the necessities of life, an offence unrelated to the death, but the charges were withdrawn two years later.

The Canadian Press is not using the girl’s last name to protect the identity of her siblings.

In her inquiry report released Wednesday, provincial court Judge Renee Cochard said efforts from children’s services appear to have been focused on removing Serenity from her mother instead of reuniting them.

Cochard said there had been previous concerns about Serenity’s health, as she was emaciated and weighed 25 pounds when she died.

Medical examiner Dr. Bernard Bannach said in his autopsy report that there were no medical explanations for Serenity’s low weight.

“Would she have been able to hang on the swing to avoid falling had she been stronger?” said Cochard.

The autopsy report was completed nearly two years after Serenity’s death due to a shortage of neuropathologists in Alberta at the time. Cochard said there was no explanation given as to why the brain dissection could not have been completed by someone outside of the province.

After the child’s brain tissue was examined, the neuropathologist said the findings were consistent with blunt trauma but did not identify the cause of the injury.

Doctors also found multiple lesions and bruises on the girl’s body and genital area, but found no signs of sexual abuse and were unable to determine the cause of the contusions.

The inquiry report said that while the children’s mother was visiting, an older sibling said she wanted to be taken away from their aunt and uncle’s home and complained about a lack of food. Children’s services interviewed the children after but had no concerns.

During a party for Serenity’s birthday in July 2013, there were complaints about Serenity and her siblings and how they appeared to be malnourished. When children’s services responded during a scheduled visit, workers said they found “everyone was dressed well and happy, except for Serenity, who was very quiet,” states Cochard’s report.

Cochard said that there were many concerning questions about the guardians’ home, including who was living in the house, who was looking after the children, how often the teens were left to look after them, and why there were no unscheduled visits by social workers.

The judge’s recommendations include that medical examiner reports be made no later than six months after a death, that all complaints about a child’s well-being be thoroughly investigated by someone who is qualified, and that children should only be taken from their mother as a last resort.

Minister of Children’s Services Mickey Amery said in a statement that his office will review the judge’s recommendations “with all of the seriousness this death deserves.” He added that the province previously implemented recommendations from the child and youth advocate relating to Serenity’s death.

He said the province also passed Serenity’s Law in 2019, which expands reporting of child abuse allegations and increases the penalty for not reporting such abuse.

The full list of Cochard’s 20 recommendations is below:

1. Ensure broad supports for Indigenous mothers, and make every effort to keep mothers and children together. If an apprehension takes place, children should be returned to their mother at the earliest possible date.
2. Medical examiners’ reports should be completed in a timely manner, no later than six months.
3. All permanent guardianship orders should specifically address the issue of access by the biological parents.
4. Biological parents should be appointed a Legal Aid lawyer as soon as their child is apprehended.
5. Biological parents and their lawyers should be granted access to all relevant documents related to apprehension and guardianship.
6. Home studies for potential guardians must be done no earlier than two months before the application is heard in court.
7. Home study reports for potential guardians must address information about both biological and foster parents.
8. When a complaint is made regarding children’s care after a permanent guardianship order has been made, it must be fully investigated by a person qualified to investigate abuse and neglect cases. Any investigative reports must be considered as part of a private guardianship application.
9. A person applying for kinship or private guardianship should have independent legal counsel.
10. Private guardianship should not be granted if there are outstanding medical or psychological issues until a court is satisfied they have been addressed.
11. If children in care are moved to a new jurisdiction, Children’s Services must notify the new jurisdiction and supply complete case files.
12. All foster parents and guardians should receive all past medical records of children in their care.
13. Children should be assessed to see if any supports are required when transitioning between foster and kinship care.
14. During abuse investigations, the investigator must have access to Children’s Services cases files, interview all members of the household and perform a home visit.
15. Proper transition time should be allowed for children moving from a long-term foster placement to kinship care.
16. During death review investigations, the Office of the Child and Youth Advocate must interview all persons who were involved with the child, even those who left their position after the child’s death.
17. All employees of Children’s Services and delegated First Nations agencies working with children in care should complete the foundations of caregiver support upon commencement of their employment.
18. The kinship assessment and support for kinship caregiving model should be implemented throughout Alberta.
19. Children should have a lawyer appointed for them in any application for private guardianship status.
20. Cochard endorsed the strategies related to child welfare outlined in a 2021 report by the Alberta Joint Working Group on Missing and Murdered Indigenous Women and Girls, specifically those that focus on reducing the apprehension of Indigenous children.

This report by The Canadian Press was first published Jan. 4, 2023.

This story was produced with the financial assistance of the Meta and Canadian Press News Fellowship.