Judge raises questions about Alberta girl’s death (2012)

2012 Judge raises questions about Alberta girl’s death in fatality inquiry

BY JACKIE L. LARSON
ORIGINALLY PUBLISHED: NOV 2, 2012

When 13-year-old Samantha Martin died, there were more questions than answers.

But a new report that says she died from natural causes brings recommendations from a judge to make sure tragedy isn’t repeated in Alberta.

A rare genetic disorder called Tetrasomy 18p left Samantha mentally and physically disabled, but her death after a life spent at a foster home touted as the answer for her grieving parents raised questions about deficiencies in the Children’s Services system. That’s according to Judge Marilena Carminati, the provincial court judge conducting the public fatality inquiry for Justice Minister Jonathan Denis.

Carminati found that while there was no link between numerous fractures, bruises and low growth and weight Samantha suffered, there wasn’t any link to her genetic condition either. Carminati said she didn’t find expert evidence that Samantha’s genetic condition caused her death.

But the judge also found Children’s Services didn’t connect the dots on Samantha’s health issues, even though complaints had been lodged by school officials. A social worker appeared to be “ill-informed” about the girl’s needs, she said.

There was a three-year gap between doctors visits in the girl’s medical history, and medical procedures recommended by a physician – including an EEG to check for seizures – were not followed up, Carminati said.

Her worker testified that although she was required to visit the girl every three months, over a two-year stretch she saw Samantha just three times.

Carminati’s report urges changes at Children’s Services.

The agency should ensure caseworkers who work with a foster child have accurate and up to date information from a reliable medical source about the child’s disability and the impact of that disability on the health, weight and fragility of the child.

“This needs to be well understood in order for the worker to make informed assessments about how the child is doing in care, especially in the case of a nonverbal child who cannot communicate concerns with the child’s worker,” Carminati wrote.

The agency’s policies should be enhanced to ensure children are actually receiving their annual medical checkups, including a diary system so the issue isn’t overlooked.

Once a recommendation is made from a school or some other reliable assessor, a doctor should examine the child and follow-up should by done by the agency, “including required entry by the Children’s Services child care worker or other support staff … into a diary system,” she wrote.

Caseworkers should have a “reasonable” case load so they have time to document and follow up on the child’s medical needs, Carminati found.

Human Services Minister Dave Hancock said lessons learned from the brief life of Samantha Martin have included a much stronger provincial support system for families with children with disabilities.

A quality review council and new structures in place for children with disabilities focus on communication where there may have once been failures to connect the dots, he said.

Hancock said he’s confident many problems with the system have been righted since Samantha’s death.

“We’re working more collaboratively than we did in the past, so the child is not on their own,” he said.

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