Review of Child's Death Finds Services Fragmented

The death of a child who was receiving government services highlights a "fragmented" government approach and "communications issues and in some instances vague standards," reported Nova Scotia's Ombudsman Office today, July 29.

Acting Ombudsman Christine Delisle-Brennan said those are among conclusions of an investigation into the child's death carried out by her office.

She said the investigation did not turn up evidence of government agents or public servants acting in "an uncaring or indifferent manner," or any specific actions or inactions by them that caused the child's death.

"Rather it revealed a series of disconnects, issues related to standards, and uncertainty of approach. What emerged from our investigation might best be described as system fragmentation."

The report is available to the media and public online at www.gov.ns.ca/ombu .

Ms. Delisle-Brennan described the Ombudsman's review as administrative in nature. She said it included the roles and responsibilities of provincial government agencies and their approach to decision-making.

"The intended outcome was not to ascribe blame, rather to independently examine government services in relation to a specific child death."

The Child Protection Services Division of the Department of Community Services was periodically involved in the child's case for several months prior to the death, and was extensively involved with the family during the three months leading up to the child's death.

There was a series of five referrals or complaints to Child Protection Services expressing concerns about the child's well-being. Two separate investigations remained open when the child died.

The child died at home. An autopsy found that death was caused by blunt abdominal trauma. A person close to the family was charged with manslaughter and was acquitted.

The investigation involved the departments of Community Services, Health and Wellness, and Justice. While the major focus is on Community Services, Ms. Delisle-Brennan said a key recommendation is to the Justice Department which is asked to lead an initiative to create a standing team to examine all child deaths and serious injuries where government services are involved.

"Automatic investigations for such cases, usually involving a team representing several government departments, are common in several provinces. We strongly endorse the principle of such a consistent and reliable response," Ms. Delisle-Brennan said.

The Ombudsman's report does not name the child. In a preface to the report entitled Should We Name the Child, Ms. Delisle-Brennan acknowledges the question was debated within her office and a decision taken not to include the child's name.

"The main reason is we believed naming the child and deliberately bringing the child's family to public attention again would serve no useful purpose. Among other considerations, siblings of the child now have reached an age at which public attention could create more harm than good.

"Naming the child, and by association the entire family, perhaps igniting again the private anguish that attends the death of any child, was unnecessary to meet our objective which is to highlight systemic concerns."