When paramedics answered a call for help at a rural gas station outside Edmonton on Nov. 20, 2009, Betty Anne Gagnon was dead.
The five-foot-two woman weighed just 65 pounds. She had bruises on her body, two black eyes and blood in her nose. And she was living with her sister and brother-in-law — who were later sentenced to 20 months in jail in relation to her death.
Denise and Michael Scriven were initially charged with manslaughter, but later pleaded guilty to failing to provide the necessaries of life.
Gagnon's death is still shrouded in some mystery. Her fatality inquiry this week, nearly eight years later, is likely to answer some outstanding questions. It's also likely to retread much of what we already know: that there were several opportunities to prevent her death in the months — even years — before it happened.
Answers that raise questions
Gagnon lived with developmental delays from a lack of oxygen at birth. But she went on to live a very independent life in Calgary, with the help of caregivers. She rode the bus by herself, held a job, loved shopping, daydreamed about swimming with dolphins and voraciously read the newspapers.
It's jarring to compare that life to her existence before she died. After her caregivers moved away from Calgary, Gagnon went to live with her sister near Edmonton, where she was eventually confined to a dog run, a feces-smeared tent, and various cages on the rural property, forced to sleep outside in an unheated school bus, beaten and called names.
- INTERACTIVE | What happened to Betty Anne Gagnon?
- Betty Anne Gagnon: Documents show warning signs ignored before death
CBC spent more than a year trying to uncover what happened, by reviewing court documents, evidence gathered for the trial (including pictures and video of the crime scene), and conducting more than 10 hours of interviews with people who have direct knowledge of the case.
The resulting picture reminds one of an old proverb:
For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the message was lost.
For want of a message the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.
The fatality inquiry will examine what happened, to possibly identify cracks in the system and look for ways to improve it. But the most heart-breaking cracks here were not systemic. They were human.
Perhaps they were horseshoe nails.
That's why the biggest question raised by Betty Anne Gagnon's tragic story is one that will not even be asked during this inquiry: what would you do in a similar situation?
Perhaps some healing can come from the recommendations to come out of this inquiry. And wider still, from the memory of her — a reminder that individuals have to step in when confronted with other Betty Annes.
Among the questions to be answered:
What could the Robin Hood Association have done?
Denise Scriven approached non-profit disabilities group the Robin Hood Association in January 2007, two years before Gagnon's death, to try to arrange professional support.
Ann Marie LePan, the director of adult services, helped her start an application. During an interview with CBC in 2013, LePan (who has been called to testify at this week's inquiry), said she could not remember if she finished the application, or whether she followed up with the family.
About a year later, Michael Scriven called the organization and was very upset. He threatened to drop Gagnon off at the agency's doors.
In that same interview with CBC, LePan said she told him he couldn't do that, and instead instructed him to call Gagnon's caseworker with the provincial government agency, called Persons With Developmental Disabilities (PDD). She also said he could take Gagnon to the emergency room at a hospital, if he was truly overwhelmed.
LePan said she called the PDD caseworker herself to tell her about Michael Scriven's strange phone call and threat.
What could the RCMP have done?
Michael Scriven's mother, Mikaela Scriven, noticed signs that something was wrong with him and his wife in the summer and fall of 2008.
"Everything was so changed," she explained during an interview with CBC. The couple were not in touch with family and there were reports from neighbours and the couple's daughter of bad fights with smashed dishes and weird behaviour — like staying up all night moving furniture around. Neither of them was working, and the power had been shut off at the house.
Mikaela worried about Gagnon's safety. So she called the RCMP. She said they told her they couldn't get involved in family matters, and that she should try to see Gagnon. She visited the property, but the couple would not bring Gagnon to the door. So she phoned police again.
They suggested she contact the family.
"When you're living with no power, nobody's working. When you can't look after yourself, how can you look after someone who's mentally challenged?" Mikaela wondered. She has also been called to testify at the inquiry this week.
"It's like, when you know something's wrong and you're telling everybody something's wrong and nobody's listening to you, you start thinking like, 'Am I nuts?' "
Strathcona RCMP spokesperson Wally Henry told CBC in 2013 they had no record of those phone calls.
What about family members?
Between September and November 2008, Denise Scriven's daughter, Hailey, also tried to get help. Then 16, her mother had kicked her out of the home, where she had lived in a basement suite with Gagnon.
Hailey joined Mikaela on a conference call with Gagnon's father, Don, and her two grown brothers. They told the men their concerns and asked that they remove Gagnon from the Scriven home. The family decided to keep her there.
"When this first went down, there was a woman who made a statement on the news, that she couldn't believe that nobody stood up for Betty Anne. But there were people who did. I did myself," Hailey told CBC in 2013.
"But nobody thought it was important enough to keep a record or even check — even just drive down the road 20 minutes and have a peek to see this wasn't the way that people should be living. All of this could have been prevented."
Michael Scriven's brother Cam was reportedly also living in the home in the weeks leading up to Gagnon's death. His name is not on the list to testify at the inquiry, nor was he mentioned in the documents outlining police evidence leading up to the trial of Denise and Michael Scriven.
What could handicapped and elder abuse groups have done?
Mikaela Scriven reports being referred to Assured Income for the Severely Handicapped (AISH) during the fall of 2008, when she was desperately trying to get Gagnon help.
That organization said they couldn't help her and reportedly referred her to Elder Abuse. Since Gagnon was not a senior, the group reportedly said they could not help either, and referred Mikaela back to the RCMP.
AISH's involvement is mentioned a second time, in an evidence file for the Scrivens' preliminary hearing, obtained by CBC News through a judge's order.
In February 2009, Denise Scriven phoned AISH to ask them to find a group home for Gagnon "as she cannot take care of client." The court record says AISH representatives told her the agency turned her away, saying they do not find housing for clients.
What was the responsibility of government agency PDD?
In February and March of 2009, Denise Scriven had three separate conversations with Gagnon's caseworker at Persons With Developmental Disabilities (PDD), the government agency that helped oversee the supports and services she received.
The caseworker, Sandy Thurston, took detailed notes about those conversations. They are outlined in court records obtained by CBC through a judge's order. She has been called to testify on Monday, the first day of the inquiry.
- Feb. 11, 2009: Denise Scriven phoned PDD and said she cannot look after Gagnon any longer. She told the worker she needed Gagnon out of the home by March 31, 2009.
- Feb. 18, 2009: Scriven met with the PDD worker, telling her she is in "a state of emergency" and not able to care for Gagnon. At this time, Scriven was on disability leave from her job as a nurse after suffering a breakdown in September 2008.
- March 12, 2009: Scriven told the PDD worker that she is in "a severe depression" and "cries all the time." She said she cannot handle simple tasks like answering phone calls.
Thurston found a new home placement for Gagnon within a few days, but was having trouble getting back in touch with Denise Scriven — who was not answering phone calls. She tried a few more times to get in touch, but her calls were not returned.
"I guess there is not a whole lot we can do until we hear back from her," she wrote in an email on April 15, 2009.
PDD closed Gagnon's file on Sept. 23, 2009 — two months before her death.
Denise and Michael Scriven, now finished serving their time in jail, have also been subpoenaed to testify this week.