Systemic flaws led to child’s death

Family and children’s services’ failure to live up to standards laid out in the Children’s Act contributed to the death of…

Family and children’s services’ failure to live up to standards laid out in the Children’s Act contributed to the death of six-week-old Samara Olson.

This is the finding of an independent review commissioned by Health and Social Services.

The critical report, which is more than two months old, was released Thursday.

“The findings of the review were that the provision of service did not, in all aspects, meet the requirements and standards for child-welfare services under the Children’s Act,” wrote Jan Christianson-Wood, a Manitoba-based social worker and special investigator of the chief medical examiner.

“A number of the shortcomings may have played a role in the events that led to the death of Samara Sky Olson.”

The mother, Justina Ellis was physically and sexually abused and neglected throughout her childhood.

She was a self-described alcoholic by age 12.

Then, on a summer night in August 2004, the young mother beat her infant child to death at her home in Dawson City.

She dumped the body in a garbage can outside a local restaurant, eventually leading police there in the early morning hours the following day.

It’s been almost two years since Olson was killed.

This week the Yukon government released a heavily censored version of a 112-page report that chronicled how government services dealt with the family before Olson died.

The risk assessment the branch conducted, which determines how safe it is to leave a child in a home, was not acceptable, stated Christianson-Wood in her report, which was delivered to the department on February 28, 2006.

Predicting a recurrence of child abuse is simpler than anticipating it for the first time.

“This is because the perpetrator has already demonstrated an ability to abuse the child,” the report said.

During Ellis’ trial in fall 2005, Crown lawyers said she had a violent past and a history of serious child abuse.

Ellis’ previous abusive behaviour made the crime more serious, said Supreme Court Justice Ron Veale in sentencing the woman to six years in federal prison.

This history of abuse should have been taken into account, said the report.

“Future decisions about the safety of that particular child have to be made based on an estimation of the risk of leaving the child with the perpetrator,” wrote Christianson-Wood.

“The child-welfare system estimates the possibility of future abuse based on an understanding of a perpetrator’s past functioning combined with the results of an assessment of the perpetrator’s present functioning and circumstances.”

For Olson, children’s services should have known the risk was high.

The assessment was “inadequate” which resulted in “an inaccurate estimation of risk,” the report said.

Once Olson was born, social workers should have done an “intensive assessment of the family’s functioning” to decide if the infant girl would be safe at home.

It didn’t happen.

Communication between the Whitehorse branch and social workers on the scene in Dawson was also lacking.

People working with Ellis and Olson in Dawson said they didn’t have enough information from children’s services about how high risk the situation was.

They also didn’t agree on what should be reported back to headquarters, the report said.

 While this lack policies and procedure for high-risk cases needs to be changed, the managers and supervisors themselves dealt with the case well, the report added.

The report contains 18 recommendations, including mandatory reporting of child abuse, the creation of a child abuse registry, the need for a policy to deal with high-risk cases, the creation of a review committee to investigate child abuse cases (that would involve social workers, RCMP, the coroner’s office, doctors, shelter workers, teachers, lawyers and First Nations representatives) and that it should be policy for government departments to share information when a child’s safety is at stake.

The department supports the recommendations, according to deputy minister John Greschner, who added that many have already come up during the Children’s Act Review.

“I think, by and large, they’re very good,” he said in an interview on Friday.

“Some require budgetary consideration, some of them really need to be worked into the work we’re doing for the new Children’s Act.

“We’ll have to consider some of (the recommendations) in that light and see what the other people (who) are involved in the system have to say about them, particularly First Nations.”

The Children’s Act review has been ongoing since September 2003.

While the Council of Yukon First Nations’ chief’s council pulled out of the process entirely for a brief time, the umbrella group is currently at the table.

It will take time to act on the recommendations, Greschner added.

“I would be surprised if, by next year at this time, all of this wasn’t old history,” he said.

“That’s an outside time. I’m sure that some of this will be in place in the next few months.”

 In a relatively short trial that concluded in the fall, Ellis was sent to Fraser Valley Institute in Abbottsford, BC, which has a special ward for women with psychological disorders.

Olson was not in state care, but was under government protection.

“At the time of her death, Samara and her parents were receiving child protection services form the Yukon’s department of Health and Social Services, family and children’s services branch due to concerns about a history of child abuse,” the report said.

However, no changes in the law or the provision of additional resources to the department are expected to be made during the current government’s mandate.

Asked about similarities between the review recommendations and a previous report on a child’s death, Greschner told a news conference that the situations are similar.

“What we’re engaged in here is reviewing an instance in which there is not a good outcome and where things went wrong,” he said on CBC Radio One.

“And, if you look at cases in which things go wrong, you find remarkable similarities from one case to the next.

“So, some of what you’re seeing here, in terms of findings and recommendations, isn’t because previous recommendations weren’t followed up or improvements weren’t made, it’s because there are similar sorts of problems in how the cases carried out, which always boils down to questions of human beings working with other human beings and having to make those judgments.”