Gaps in care assessment led to deaths, serious injuries: Alberta’s child and youth advocate – CBC

Report on Child Welfare System Deficiencies in Alberta

Executive Summary

An investigative review by Alberta’s child and youth advocate into 69 cases of death or serious injury has identified significant gaps in the child intervention system. The report, “Calling for Change,” indicates that in over half of the cases reviewed, assessments of caregiver capacity and the impact of relational disruptions were inadequate. These systemic failures directly challenge the achievement of several Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 10 (Reduced Inequalities), and SDG 16 (Peace, Justice and Strong Institutions). The findings call for urgent reforms to address trauma, improve support for youth transitioning out of care, and rectify the disproportionate impact on Indigenous children.

Analysis of Findings in the Context of Sustainable Development Goals (SDGs)

SDG 3: Good Health and Well-being

The report’s findings represent a critical failure to ensure the health and well-being of vulnerable children, a core tenet of SDG 3. The cycle of unaddressed trauma leading to severe behavioural challenges and substance abuse directly contravenes targets for mental health and substance abuse prevention.

• The review covered 60 deaths and nine serious injuries.
• Of the 60 deaths, 33 were the result of unintentional drug or alcohol poisoning, highlighting a crisis in achieving SDG Target 3.5 (strengthen the prevention and treatment of substance abuse).
• The failure to identify and treat trauma early in a child’s life undermines SDG Target 3.4 (promote mental health and well-being).

SDG 16: Peace, Justice and Strong Institutions

The advocate’s report exposes weaknesses in public institutions responsible for protecting children, pointing to a need for more effective, accountable, and transparent systems as outlined in SDG 16.

• Institutional Failure: Child intervention workers failed to adequately evaluate critical risk factors in more than 50% of cases.
• Lack of Accountability: Despite repeated involvement, children were returned to unsafe environments, leading to fatal outcomes. This challenges the objective of SDG Target 16.2 (end abuse, exploitation, and all forms of violence against children).
• Transparency: Of 23 recent recommendations made by the advocate’s office, only five have seen significant progress, indicating a gap in institutional responsiveness and accountability (SDG Target 16.6).

SDG 10: Reduced Inequalities

The data reveals a severe and disproportionate impact on Indigenous youth, underscoring systemic inequalities that conflict with the principles of SDG 10.

• Approximately two-thirds of the young people in the 69 cases reviewed were Indigenous.
• The report notes deep concern regarding the “over-involvement of government systems in the lives of Indigenous People,” pointing to a failure to achieve SDG Target 10.2 (promote social inclusion) and Target 10.3 (ensure equal opportunity).
• Advocates call for the integration of cultural approaches to Indigenous parenting and child care, which is essential for creating equitable outcomes.

SDG 1: No Poverty

The report highlights the precarious situation of young adults aging out of government care, linking inadequate support systems to an increased risk of poverty and homelessness, an issue addressed by SDG 1.

• The Transition to Adulthood Program (TAP) currently ceases financial support at age 22, a policy linked to negative outcomes such as houselessness for former youth in care.
• Recommendations to extend TAP eligibility to age 24, 26, or even 29 are aimed at strengthening social protection systems (SDG Target 1.3) and preventing a transition from state care into poverty.

Case Studies Illustrating Systemic Gaps

• A 19-year-old boy, who had explicitly stated it was unsafe to live with his parents due to substance abuse and family violence, was repeatedly returned to their care. He subsequently died from an accidental substance poisoning.
• A nine-month-old infant was hospitalized after ingesting opioids and methamphetamines. Despite this, she was returned to her family with a safety plan. The child died at 19 months of age from drug poisoning.

Recommendations and Government Response

Proposed Interventions for Systemic Reform

1. Implement mandatory training on the impact of trauma for all provincial employees working with young people.
2. Adopt enhanced systems to better identify and support young people affected by trauma.
3. Increase support for young adults transitioning out of care by extending the age of eligibility for the Transition to Adulthood Program (TAP).
4. Improve transparency by making the TAP policy manual publicly available so young people understand their entitlements.

Government Position

• The Minister of Children and Family Services stated that the government’s focus is on increasing supports for children under the age of 18 to build resilience for adulthood.
• The ministry noted that 91% of eligible children who turned 18 continued to receive non-financial support from TAP.
• No commitment was made to raising the age of eligibility for financial support through the TAP program.

1. SDGs Addressed in the Article

SDG 3: Good Health and Well-being

• The article extensively discusses issues of health and well-being, particularly concerning vulnerable children and youth. It highlights deaths from drug and alcohol poisoning, the impact of trauma on mental health, and the development of addictions. The call for better systems to identify and treat trauma directly relates to promoting mental health and well-being.

SDG 10: Reduced Inequalities

• The article points to significant inequalities by stating that “About two-thirds of the young people were Indigenous” among the cases reviewed. It mentions the advocate’s concern about the “over-involvement of government systems in the lives of Indigenous People” and includes a call for “cultural approaches about Indigenous parenting,” highlighting the need to address systemic inequalities affecting this group.

SDG 16: Peace, Justice, and Strong Institutions

• The core of the article is a critique of a public institution—the child intervention services. It identifies “gaps” in assessment, failures to protect children, and a lack of progress on past recommendations. The advocate’s report, “Calling for Change,” and recommendations for mandatory training and policy transparency (making the TAP manual public) are direct efforts to build more effective, accountable, and just institutions to protect children.

2. Specific Targets Identified

Targets under SDG 3: Good Health and Well-being

• Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. The article’s focus on preventing deaths among young people and the recommendation for “mandatory training on the impact of trauma” and “better systems to identify young people with trauma” directly support the goal of promoting mental health and well-being to prevent tragic outcomes.
• Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol. This target is directly relevant as the article states that 33 of the 60 deaths were from “unintentional drug or alcohol poisoning.” It also describes a cycle where trauma leads to “developing addictions” and mentions parents with “substance abuse” problems, underscoring the need for stronger prevention and treatment measures.

Targets under SDG 10: Reduced Inequalities

• Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, race, ethnicity, or other status. The article highlights the disproportionate number of Indigenous youth (two-thirds) in the cases, indicating a lack of inclusion and protection for this group. The call for “cultural approaches” and support for Indigenous children is an effort to promote their inclusion and well-being.
• Target 10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory policies and practices. The advocate’s report points to systemic failures that result in unequal outcomes, particularly for Indigenous youth. The “over-involvement of government systems” suggests a practice that needs reform to ensure equal opportunity for safety and well-being.

Targets under SDG 16: Peace, Justice, and Strong Institutions

• Target 16.2: End abuse, exploitation, trafficking and all forms of violence against and torture of children. The cases of death and serious injury resulting from systemic failures, such as returning a child to an unsafe home or a baby dying from drug poisoning after being sent home, represent the ultimate failure to protect children from harm, neglect, and violence.
• Target 16.6: Develop effective, accountable and transparent institutions at all levels. The entire article is a call for this. The advocate’s review exposes a lack of effectiveness in child intervention services. The recommendation to make the Transition to Adulthood Program (TAP) manual public is a direct call for transparency, and the tracking of progress on past recommendations is a measure of institutional accountability.

3. Indicators Mentioned or Implied

Indicators for SDG 3

• Mortality Rate: The article provides specific numbers that can be used as indicators of premature mortality. It states there were “60 deaths and nine serious injuries” reviewed, and more specifically, “33 of the young people died of unintentional drug or alcohol poisoning.”
• Prevalence of Substance Abuse and Mental Health Issues: While not providing a statistical prevalence rate, the article implies this is a key indicator by noting the cycle of “escalating behavioural challenges and developing addictions” stemming from untreated trauma. The case of a boy whose parents had “substance abuse and family violence problems” also points to this as a critical factor.

Indicators for SDG 10

• Proportion of a specific population group affected: A clear indicator of inequality is the statistic that “About two-thirds of the young people [in the review] were Indigenous.” This proportion measures the over-representation of a specific ethnic group in negative outcomes within the child welfare system.

Indicators for SDG 16

• Number of child deaths and injuries under government care: The “69 deaths and serious injuries” reviewed by the advocate serves as a direct indicator of the institution’s failure to protect children under its mandate (related to Target 16.2).
• Implementation rate of recommendations: The article provides a clear indicator of institutional accountability by stating that of “23 recommendations advocates have made to government in recent years, five had ‘significant progress made.’” This measures the government’s responsiveness to oversight.
• Public Access to Information: The call to “make its policy manual public for a program aimed at helping those young adults” (the TAP manual) implies an indicator of institutional transparency. Whether the manual is public or not is a measurable outcome.

4. Table of SDGs, Targets, and Indicators

Source: cbc.ca