Fatality inquiry examined the circumstances of 4-year-old Serenity’s death

Warning: This story contains a graphic image.

CBC News: The death of a four-year-old Cree girl in 2014 was the result of her being taken away from her mother by Children’s Services years earlier, an Alberta judge has found.  The young girl, Serenity, was living with her great aunt and uncle in a kinship care arrangement in Maskwacis, Alta., when she sustained a major head injury on Sept. 18, 2014.

She died in hospital after being taken off life support on Sept. 27, 2014.

When details of her death became public — along with photos of her bruised and emaciated body in hospital — a wave of public outrage prompted several investigations, lawsuits and ultimately reform of provincial child welfare laws.

In 2017, the caregivers were charged with a single count of failing to provide the necessaries of life. That charge was withdrawn in 2019 when Crown prosecutors said there was no longer a reasonable likelihood of conviction.

A public fatality inquiry was held in 2021, overseen by provincial court Judge Renee Cochard.

CBC is not publishing Serenity’s surname, or identifying her mother or her caregivers, in order to protect the identities of Serenity’s siblings.

More than eight years after Serenity’s death, Cochard’s 117-page report was published Wednesday. It concludes that despite numerous investigations, there are still many unanswered questions about what happened.

Still, Cochard points to failings by Children’s Services and other agencies and officials that Serenity encountered in her short life. “What led up to her death started the day she was removed from the care of her mother,” Cochard wrote in her report.

Cochard found that Children’s Services was on a quest to prevent Serenity’s mother from regaining custody of the little girl and her two older half-siblings, who were also placed with the great aunt and uncle. “The entire system appears to have worked against this goal, despite [the mother] maintaining a strong involvement with her children throughout and making best efforts to meet the demands of Children’s Services,” the judge said in the report.

• Serenity’s mother tells inquiry relationship with caseworker was difficult from start

Cochard cites the final report of the National Inquiry into Missing and Murdered Indigenous Women and Girls, which found that the apprehension of Indigenous children from their families is a form of discrimination that is incentivized by state funding. “As the report found, apprehension is a form of violence against the child and mother,” the judge said in her report. “In this case, the result of that violence was Serenity’s death.” 

Cochard makes 20 recommendations to help prevent similar deaths in the future. A list of the recommendations, the majority of which are directed at the Children’s Services ministry, can be found at the end of this story.

Minister of Children’s Services Mickey Amery’s office did not respond when asked if the ministry will adopt the recommendations, but said in a written statement said that substantial changes have already been made. “We will continue to make and support improvements going forward, including reviewing the fatality inquiry judge’s recommendations with all of the seriousness this death deserves,” Amery said.

In an interview with CBC, Serenity’s mother said she thinks the recommendations are good but worries they won’t be acted upon. “I’m glad that child welfare is being outed for their mistakes and their wrongdoings, but it still doesn’t change the fact that there was not justice for Serenity,” she said. 

How did Serenity die?

Cochard found that the cause of Serenity’s death was a serious brain injury sustained when she fell from a tire swing in her guardian’s yard, and that the death was accidental. “We will never know exactly what happened on that day except that Serenity was on the swing, fell and hit her head causing massive brain damage,” Cochard said. 

The finding is difficult for Serenity’s mother because the medical examiner who did the autopsy originally reported that while it was possible a fall caused Serenity’s injury, the exact circumstances could not be determined.

Cochard was also struck by the evidence that Serenity was severely emaciated at the time of her death, and noted that a specialist who examined the child while she was in hospital wondered if the child’s poor condition played a role in the fall. “Would she have been able to hang on to the swing to avoid falling had she been stronger?” Cochard wrote.

The final report from the medical examiner wasn’t completed until 2016 — the inquiry heard that was because of difficulty in finding a neuropathologist to examine Serenity’s brain due to understaffing in Alberta.

Cochard found that the delay in a report being produced caused unnecessary and prolonged stress for the family. According to the inquiry report, medical notes made during Serenity’s hospitalization indicated evidence of possible sexual abuse, but during the autopsy the medical examiner determined there were no signs of it.

“This has caused the family a great deal of anxiety and could have easily been avoided if the report had been completed on time,” Cochard said. “A preliminary report produced without the neuropathologist’s report would have alleviated the family’s uncertainty.”

Findings about Children’s Services

Cochard’s report details the actions of the various child welfare workers that Serenity and her mother dealt with over the years, and finds that the “default position” of Children’s Services seemed to be to take the children away from their mother. In-depth reporting from CBC on the details of how Serenity and her siblings ended up in the child welfare system, and how their mother tried to get help when she believed her children were mistreated, can be read here. 

Cochard found that an affidavit sworn by Serenity’s mother’s longtime caseworker Leanne Worthington, made in support of the great aunt and uncle’s private guardianship application, was “filled with, at best, misinformation and omissions, at worst, deliberate misleading statements.”

The judge found Worthington’s case notes painted a picture of Serenity’s mother trying hard to follow through on all directions given to her, while receiving nearly no help or support from Children’s Services.

• Key witness collapses while giving evidence in Serenity inquiry

Serenity’s siblings lived with their mother until they were apprehended in 2010. Serenity was taken in 2011 when she was six months old, after her mother made a report about being a victim of domestic violence.

Cochard found that the reasons for apprehending the children did not meet the high bar that warrants separating a family. “In this case, I do not find these concerns existed and if they did, they could have been addressed in a manner to ensure the children remained with their mother,” the judge wrote.

The judge was critical of how Children’s Services workers rushed to place Serenity and her half siblings first in a permanent guardianship, and later a private guardianship placement with the great aunt and uncle, despite objections raised by Serenity’s mother and others.

Cochard noted that caseworker supervisor Pamela Orr’s testimony left the impression that Children’s Services was more concerned with process than with the welfare of the children. “When asked about that short transition process, Ms. Orr’s response was that of a person whose interest was not of the best interests of the child, but the best interests of the adults involved,” Cochard said.

During the inquiry Lise LaPlante, who was a caseworker trainee at the time she worked with Serenity’s family, defended how Children’s Services responded to allegations of neglect and abuse in the kinship home in 2013. 

Cochard found that many red flags were missed that should have been better investigated. “Overall, Ms. LaPlante’s testimony left me with the impression that she was trying hard to protect herself and Children’s Services from wrongdoing,” Cochard said.

Cochard was also critical of many other workers, agencies and figures — including the special investigator who admitted to rushing the investigation of abuse allegations and a doctor who didn’t follow up when Serenity was never brought in for follow-up appointments about her weight. 

The inquiry report also found that a Children’s Services visit supervisor who raised concerns about the children being placed with the great aunt and uncle was fired shortly after, in April 2013. In October 2013, once the private guardianship order was made, Children’s Services closed its files on Serenity and her siblings.

• Social worker, investigator involved in Serenity’s kinship case felt rushed, inquiry hears

Jurisdiction over the children was transferred to Akamkisipatinaw Ohpikihawasowin Child and Family Services (AKO) — an on-reserve child welfare agency at Maskwacis. It no longer exists.

But Cochard found that neither Children’s Services or AKO took steps to ensure that important information about the children was transferred between the two agencies.

Cochard noted that AKO also failed to properly follow up on a report to RCMP about how thin the children had gotten when they were seen wandering alone in West Edmonton Mall by security in June 2014 — just a few months before Serenity’s death. The inquiry also heard about policy and practice changes that Children’s Services has made since Serenity’s death. Cochard found that while there have been improvements, further work is needed. 

Findings about the kinship caregivers

Serenity’s great aunt and uncle have previously denied all allegations that there was abuse and neglect in their home. While giving evidence during the inquiry, the great aunt said they did not have a lawyer and believed they didn’t have all the information they needed about Serenity and her siblings before they gained custody of them.

“It is most unfortunate that [the great aunt] believed she was lacking information regarding the children, responsibilities regarding kinship care and obligations of private guardians. All of this could have been easily provided by Children’s Services and a lawyer should have been appointed to advise her,” Cochard said.

Calls for change

Serenity’s mother gave evidence during the inquiry that left Cochard with the impression of an intelligent, concerned parent devoted to her surviving children’s well-being. The mother, now in her 30s, lives in British Columbia. She and her partner have five children.

Cochard found that even though Serenity’s mother was struggling as a young person, she had bonded with and cared for her kids when they were apprehended. “She never lost sight of wanting to get her children back. She could have walked away, but she did not. Children’s Services has spent thousands of dollars keeping these children away from their mother,” Cochard said. 

“Had this money been spent on providing services to [the mother], such as childcare support, a home, proper financial help … the inquiry’s view is that the end result would have been much different.”

Serenity’s mother said she appreciates that Cochard acknowledged what her family has gone through, but is skeptical that there is a willingness in Alberta to change the system. “Our younger generation — they aren’t going to do better if the system doesn’t do better,” she said.

Based on her findings, Cochard makes 20 recommendations for changes that she believes could help prevent deaths similar to Serenity’s in the future:

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.

The fatality inquiry office has sent requests for responses to the recommendations to Alberta Health Services, Children’s Services, the deputy minister of Justice, Legal Aid, the Office of the Chief Medical Examiner and the Office of the Child and Youth Advocate.

ABOUT THE AUTHOR

Paige Parsons

Reporter

Paige Parsons is a reporter with CBC Edmonton. She has specialized in justice issues and city hall, but now covers anything from politics to rural culture. She previously worked for the Edmonton Journal. She can be reached at paige.parsons@cbc.ca.