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Major planning, assessment problems led to child's death at mother's hands: report

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A false assumption that a women’s residential housing shelter in Winnipeg’s North End was a "safe house" led to major issues with case planning and assessment for a troubled mother who killed her child there, a Manitoba judge has found.

This is just one of several observations Judge Larry Allen makes in a wide-ranging report into the June 2009 death of Jaylene Redhead, aged 20 months, at the Native Women’s Transition Centre.

The report was released this morning.

Jaylene was abused and suffocated by her mother, Nicole Redhead, who is now serving a 12-year prison sentence for manslaughter. It was Redhead’s fourth stay at the NWTC after three prior attempts at living there while trying to get her life together didn’t work.

Redhead, an abused woman from a background of extreme trauma, drank and was a long-term serious crack cocaine addict. She had two other children apprehended by CFS before becoming pregnant with Jaylene.

The Awasis CFS agency seized Jaylene at birth, but Redhead was allowed to reclaim and care for her at NWTC under a temporary supervision order in December 2008.

A month later, she resumed using crack while living at the NWTC and was "partying" away from the facility on weekends while leaving Jaylene with her grandmother.

The inquest, comprising 41 days of testimony, focused on several aspects of Redhead’s interactions with the Awasis Child and Family Services agency and the NWTC and the level of supervision she received while living there.

The hearings uncovered serious problems with communication, documentation and oversight of Redhead’s case and Jaylene’s care, along with workload and compensation issues at Awasis.

Allen also examined how the two service providers did — and didn’t — work together in handling Redhead’s file and particular needs, which were considerable given her addictions issues.

One of the foundational problems the inquest heard of was how Awasis was under the impression the NWTC was a "safe house" for clients, a description the NWTC rebuffed.

This mistaken assumption led to a downgrading by Awasis of Redhead’s risk as a caregiver.

"It is clear from the testimony provided at the Inquest that the NWTC was not, as advertised, a 'safe house,'" Allen said.

"The Centre itself has gone a long way to rectifying perceived problems. The Awasis Agency understandably appears to have misunderstood how NWTC was being run. It should never be the case again that the rules and practises of that facility are left as nebulous as they were preceding Jaylene Redhead’s death," Allen stated.

Allen noted how Redhead frequently left the facility but wasn’t tested for drug or alcohol use upon her return.

"If the Awasis Agency felt that NWTC was the preferable option for Nicole Redhead, then they simply had to make sure that she was randomly tested as to her sobriety," Allen wrote. "Because this was not done, the Agency moved forward with false information and the risk to the child was not perceived."

Allen makes a slew of recommendations for change in hopes of preventing similar deaths in the future. They include, but are not limited to:

  • Revamping provincial standards for CFS social workers so that they’re more "usable" to them on the job.
  • The development of standards for services provided by "satellite" agencies like NWTC to clients, to be monitored by the Child Protection Branch.
  • Making drug and alcohol testing kits available to Manitoba’s CFS authorities at no cost.
  • Making it so random drug and alcohol testing is considered by CFS in all child-protection cases where a custodial parent has an addictions issues.
  • That the government add more resources for Fetal Alcohol Spectrum Disorder specialists for CFS authorities.
  • That the Northern Authority (which oversees Awasis) enforce the importance of regular risk assessments for kids in a parent’s care but are being supervised by CFS.

Allen also urged the Manitoba government to do "everything possible" to foster better collaboration between actors in child-welfare.

"…One cannot help but think that the frontline workers of the various Authorities should have opportunities to conference and share ideas. These people are working in one of the most difficult work places in this province and they need considerable support. One place to get that support is from each other in an environment that does not include the stress of being on the job," Allen said.

"Further, if this kind of interaction could include staff of the O.C.A., the Child Protection Branch and satellite providers like the NWTC, one would hope that not only would this improve communication between all these people and their respective agencies, but it would go towards reminding them all that they are truly working for the same objective."

 

Province working on recommendations

Manitoba Family Services Minister Kerri Irvin-Ross accepted Allen's recommendations, saying they will help better protect kids in CFS care.

Her department has begun the process of sorting out how to implement them without overlapping on more than 60 recommendations for change recently outlined by Phoenix Sinclair Inquiry Commissioner Ted Hughes.

Irvin-Ross said in an interview with the Free Press she's keenly interested in fostering greater collaboration between CFS and satellite agencies.

"We need to be able to work together for the best interests of children," she said.

Clearer standards for front-line social workers are being developed, Irvin-Ross said.

As well, the government is moving ahead with analysis of a possible new computer system to replace the outdated database used by CFS currently.

Lack of access, incomplete data and missing documentation in the current system have long been pointed to as a problem.

Irvin-Ross called Jaylene's killing "incomprehensible."

"Judge Allen has outlined a path to make sure we are protecting children," she said.

 

History

Updated on Friday, May 23, 2014 at 12:07 PM CDT: Adds report.

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