"Organizational failure" delayed case review report of child's death.

Why did it take more than three years to complete the case review after the violent death of Sherry Charlie while she was under the supervision of a child welfare agency?

Jane Morley, BC's independent Child and Youth Officer, investigated and found that "the story of this Director's case review is not a story of conspiracy and cover-up, but rather one of organizational failure."

At the centre of the failure was a lack of clarity about what a case review was all about, its core principles and how case review fit within MCFD's organizational objectives.

The 19 month old child was killed in the home of a relative in which she had been placed by the Nuu-Chah-Nulth children's service. Her great uncle had a criminal record of violence, and is now serving a sentence of manslaughter in her death. The circumstances required a review of the agencies performance by the Director of Child Protection.

The length of time it took to complete and publish the Director's case review became a contentious issue in the legislature and the media. Charges of cover-up and ministerial interference were heard.

The Minister of Child and Family Development requested Morley to look into the review process in this case.

Morely found no cover-up and blamed organizational problems including:

* a reorganization of child protection services, that shifted responsibilities to aboriginal and other organizations,

* budget cuts and staff reductions,

* lack of clarity that caused the Directors case review report to go through 25 drafts over a three year period.

During this period the senior staff focussed their attention on the shifting governance issues and not operational matters. The lack of attention exacerbated the usual tensions between the front line and the "centre".

Morely points out that the BC's Director of Child Protection is legally the "protector and guardian of children" but operational responsibility for the service is managed in the local agencies. The decentralization of child welfare is dictated by the nature of the work which requires "judgment calls in particular interactions with children, youth and families in crisis." However, when failure occurs in the system, the social and political consequence go beyond local concerns.

"No one I interviewed was satisfied with the time it took to produce this Director's case review. No one told me that that much time was required or was acceptable."

The recent BC Budget calls for a substantial rise in funding which will provide more staff for child protection, including review staff.

Among Jane Morley' recommendations are:

* Expand case reviews to cover deaths and critical incidents of all children and youth who have received services under MCFD's broader mandate, when those services and the practice related to them may have significantly affected the outcome of the case.

* When more than one area of practice or service is involved, conduct an integrated case review, with joint responsibility for terms of reference and recommendations resting with the responsible managers.

* In consultation with Aboriginal delegated agencies, and with agencies contracted to provide services, develop mutual and clearly stated expectations of respective roles in case reviews when the agencies' services and employees' practice are being reviewed.

www.gov.bc.ca/cyo/