Bernard Richard warned New Brunswick that the detection of child neglect required a sense of urgency.
Ten years ago, after the death of 27-month-old Juli-Anna St. Peter, the former child and youth watchdog made recommendations to the province for how to keep vulnerable children safer.
Today, Richard worries his report has gone untouched.
The public needs to know "a lot more than it knows now" about the deaths of vulnerable children, Richard said in an interview from British Columbia, where he is the children and youth representative.
"I'm still stunned that these investigations go on behind closed doors," he said.
In New Brunswick, child deaths are investigated by a committee set up 20 years ago after a Saint John girl, Jackie Brewer, died of neglect.
A CBC News investigation has found that at least 53 vulnerable children known to child protection services have died from unnatural causes in the past two decades.
Little is known about those children or if anything could have been done to save them.
The committee makes its vague recommendations public, but they're delivered unattached to a human story. The public learns almost nothing about their lives or their deaths.
The Department of Justice and Public Safety says the committee's reports are protected by privacy legislation and must remain confidential because they're considered "advice to minister."
But for Richard, it's a matter of dignity.
"A child that dies doesn't need to be anonymous, shouldn't be anonymous," he said.
"Their life has some value. We should talk about their life, but also the circumstances of their death, and make improvements."
Not enough to save Juli-Anna
When 28-month-old Jackie Brewer died in 1996, the government promised to do better job of training social workers to detect chronic neglect.
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But the promise wasn't enough to save Juli-Anna St. Peter.
On April 13, 2004, Juli-Anna died in a Woodstock hospital after a pen-like object perforated her bowel.
Her mother, Anna Mooers, was sentenced to 27 months in prison for criminal negligence causing death.
Richard, who was New Brunswick's child and youth advocate at the time, determined that officials never launched an official investigation into the family, despite allegations of abuse and neglect.
The family had been the subject of at least 16 child protection referrals.
The sources of the complaints were reliable, including an emergency room doctor, the town's mayor and Juli-Anna's grandmother. But the children remained in the home.
In his report at the time, "Broken Promises: Juli-Anna's story," Richard noted the similarities between Jackie and Juli-Anna, describing the situations as "virtually identical."
Many of the problems highlighted in Jackie's case, he noted, were still an issue eight years later when Juli-Anna died.
That includes social worker burnout, taking parents' explanations at face value and not taking cases of child neglect seriously enough.
"It appears a lack of clear understanding and direction regarding cases of child neglect persists," the report says.
He concluded Juli-Anna's death could have, and should have, been prevented.
Today, Richard remains motivated by the haunting look on Juli-Anna's face. Her portrait sits in his office at home.
"Providing more information, shedding more light, being more transparent when these kinds of tragedies arise allows all of us to be better citizens and to look out for the interests of kids," he said in an interview.
'It's going to probably happen again'
Not everyone agrees more information is better.
Publicizing details about child deaths could add context, but could also retraumatize families, according to Miguel LeBlanc, executive director of the New Brunswick Association of Social Workers.
"Let's not forget the family," he said.
But Juli-Anna's grandmother, Donna Hitchcock, suspects that the secrecy around child death reviews has led to the forgetting of the victims themselves.
In an interview from her home in Alberta, she said she hoped government officials and child protection workers "will open up their eyes."
Juli-Anna's death prompted calls for better training and more resources for social workers in rural New Brunswick.
Since then, LeBlanc said, the province has brought in experts in neglect and has adopted a new model to assess child protection referrals.
LeBlanc believes the system has improved since Jackie and Juli-Anna died, but said more could be done.
"The goal is always to prevent another Juli-Anna," he said.
"But will it happen in the future? Unfortunately, it's going to probably happen again."
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