The province's Representative for Children and Youth says abuse, instability and constantly changing placements led to a teenager in provincial care to take his own life by jumping from a window at an Abbotsford hotel.
The report — Broken Promises — details the life of Alex Gervais. Gervais was in 17 different placements and under the watch of 23 different social workers and caregivers from the time he entered provincial care to the time he died at 18.
"Alex lived the life that none of us would wish for our own children or any child," said the acting representative for Children and Youth, Bernard Richard. "His journey through the child welfare system was marked by constant instability, a distinct lack of permanent connection and trauma."
The report marks the first from acting representative Bernard Richard.
The report explains the goal for the Ministry of Children and Family Development (MCFD) is to find permanent homes for youth in care, something that never happened for Gervais.
The report details a number of failings by MCFD and the delegated Aboriginal agency from the time Gervais moved to British Columbia.
According to the report's findings, opportunities were missed to place Alex with his stepmother in B.C. or with his aunt in Quebec.
Investigators found no reason why no real effort was made by MCFD to place Alex with those family members.
"These opportunities were not seized as they should have been and instead the de facto plan for Alex would be he would eventually age out of care," said Richard.
Gervais also received five separate referrals to Child and Youth Mental Health Services while in care and he was never connected with those services.
The report also notes the Ministry of Children and Family Development ignored the duty to connect Gervais with his Metis roots.
Eventually, the provincial government severed ties with that agency.
During his time in the agency's care, the teenager complained of being sexually assaulted. He also complained about a lack of food in his residence and not being provided enough money to buy clothing.
The last option for the province was to move Gervais to the Abbotsford hotel where he eventually took his own life.
A caregiver was given more than $8,000 a month to care for Gervais and the Delegated Aboriginal Agency paid for the caregiver to live in the adjacent room, but the report found he was rarely there.
"But this caregiver was rarely on site — in fact, he hadn't been there at all in the 10 days before Alex's death — and Alex complained bitterly that the caregiver was pocketing the money meant for him to purchase food and clothing," reads the report.
The first is for the MCFD to provide necessary support for children and youth in care who are unable to return to their birth families.
The report also calls on the MCFD to take immediate steps to ensure children and youth in care who have been identified with mental health needs receive timely and uninterrupted care and to enhance oversight of all contracted residential agencies.
The provincial government says it accepts all four of the recommendations. Children and Family Development Minister Stephanie Cadieux announced Monday a number of things the province has done recently and is planning to do.
She said the province is updating it's computer system to automatically alert the head of child welfare when a child is bouncing from placement to placement.
Social workers with MCFD have also visited all 700 children currently in contracted care since Jan. 1.
"We need to get to a place where contracted residential services are the exception, not the rule," said Cadieux. "There are no arguments with the facts in this report. If I had written it, it would have said the same thing."
"I can't go back and I certainly can't comment on the decisions made at the time on the ground. But what I can say is that I agree that they were not the right ones. It should have been different for Alex, and we want it to be."
The province also announced $2.7 million to develop culturally specific plans of care that are responsive to the specific community and culture of each child.