A disabled 13-year-old girl who died shortly after spending most of her life in foster care was failed by Alberta's foster care system, a fatality inquiry has found.

The report, written by Provincial Court Judge Marilena Carminati, found Samantha Martin was malnourished — weighing only 51 pounds at 12 years of age — and went for prolonged periods without seeing a doctor even though she had a rare genetic abnormality, and should have seen a physician every few months.

"It was totally preventable. She should be with us today," said Samantha's mother Velvet Martin, who received the report this week.

Samantha died in December 2006, five months after she began living full-time with her biological family.

The judge ruled Samantha died of natural causes, likely a seizure, but she pointed out that doctors acknowledge untreated seizures carry a greater risk of death.

While Carminati ruled the cause of death undetermined, she made a number of recommendations to prevent similar deaths in the future.

  • Children's Services should ensure that those case workers who work with a foster child have accurate and up-to-date information from a reliable medical source about the child's disability
  • Children's Services should look at enhancing policies to ensure children are actually receiving their annual medical checkups as required
  • When a recommendation is made by a reliable source (such as a school assessment), a doctor examine the child for possible medical issues
  • Ensure caseworkers for the child have reasonable case load so they have time need to adequately document and follow-up on medical needs of the child

Velvet Martin said she doubts the recommendations will change anything.

"So many cases of families that have been wronged," she said. "There is a lack of follow through, repercussions and deterrence.

"Until we establish some sort of mechansim to hold people accountable, there will be no change," she said.

Shortly after Samantha was born with the chromosomal abnormality called Tetrasomy 18p, her parents put her in foster care upon the advice of workers from the provincial department of Children’s Services.

The family was told Samantha would have access to better medical treatment, the inquiry heard.

But her life in foster care left her undernourished, suffering unexplained bruises and fractures, and only occasional visits with doctors and social workers.

School staff raised concerns with Alberta Children's Services over Samantha's frequent injuries, the meager contents of Samantha's lunches fractures and her seizures.

A pediatrician testified at the hearing that he ususally sees children with Samantha's condition every three months and noted her medical file was unusually thin.

In fact, her medical records show a gap of three years between doctor visits.

Samantha also went long periods of time between visits with a social worker. Samantha's social worker was supposed to meet with the girl every three months, but documents show gaps between visits of up to 14 months.

The social worker testified there were two visits in that period, but she never found the time to complete her paperwork.

At the hearing, the same social worker testified "she would never have been able to find a placement for Samantha that would have been equal to — let alone better than — the quality of care she was receiving in the foster home."