Another child whose life we wrote off

"The Ministry of Children and Family Development missed opportunities to learn from its mistakes by failing to review a number of infant deaths, B.C.'s independent child advocate says," reports Lindsay Kines in the Times Colonist today.
"Mary Ellen Turpel-Lafond, who examined the deaths of 21 infants for a recent report, noted that the ministry conducted its own internal investigations in just 14 of the cases."
All the deaths should have been reviewed based on the ministry's standards, the representative found. In the 14 deaths that were reviewed, "a number took too long complete, ignored key issues or failed to recommend changes that would fix identified problems."
The representative also said regional directors were reviewing cases in which they were involved - an obvious conflict of interest. Minister Mary Polak agreed and said some changes would be made. But the ministry has been "transforming" itself for years with no clear improvements. Where is the accountability for managers who failed to ensure an effective independent review process?
The article is here.
The representatives report, Fragile Lives, Fragmented Systems, is here.

But the individual case studies from the report tell much of the story.
Here's the second one. (The first one is in the post below.)

Case Example Two
This First Nations child was born into a home with other young children. The family lived in poverty and often relied on relatives, transition housing and motels for accommodation. MCFD became aware that the mother was expecting early in her pregnancy.
The mother had been admitted to hospital after being assaulted by her spouse during her pregnancy. Prior to the infant�s birth, 14 child protection reports had been made to the ministry, primarily about alcohol abuse and domestic violence. Four of these reports were made while the mother was pregnant with this infant; they included concerns about inadequate housing, emotional abuse of the infant�s siblings and substance abuse. One of the reports was investigated and not substantiated. The other three were not investigated. The MCFD file was closed before the infant was born.
According to the MCFD file information, the newborn was assessed at birth by a program in the local hospital that worked in conjunction with the public health unit. The program reportedly assessed newborns for medical as well as social/emotional risk factors. The newborn was assessed by the program as low risk and was discharged from hospital the following day. It does not appear the hospital was aware that the family had no reasonable housing and a history of substance abuse and family violence. It appears this MCFD information was not shared with the hospital following the infant�s birth.
The infant was seen three times by public health nurses from birth to three months of age. At the second visit, the mother reported that the infant had noisy breathing while asleep, which a doctor thought was possibly the result of a floppy epiglottis.
Approximately two months later the mother took the infant to see a doctor because the noisy breathing persisted and a cough had developed. The doctor thought these symptoms were possibly due to an infection and prescribed amoxicillin. At the third visit with the public health nurse, the mother informed the nurse that the infant�s noisy breathing persisted, and she also informed the nurse about the previous visit to the doctor. No follow-up regarding the infant�s breathing was noted on the record of the visit.
The infant died four days after the last visit with the public health nurse. On the evening of the death the infant had been left in the care of adolescent babysitters. There was no crib in the home. The babysitters placed the infant to sleep in a car seat that was on top of a soft mattress. Sometime later the car seat turned over, and the baby was asphyxiated.

The key point is that the child's bleak future was foreseeable and the death could have been avoided. The baby never really had a chance and no one took the small steps that could have made a difference for the children in this messed-up family.