At least 53 children known to child protection services in New Brunswick have died from unnatural causes over the past two decades.
How they died and whether any could have been saved is not for the public to know, according to the provincial government.
That's because a committee, created in 1997 to shine a light on the deaths of at-risk children, labours almost entirely in the shadows, a CBC News investigation has found.
Even the conclusions drawn by New Brunswick's child death review committee are not shared with the public.
"The public has almost no perception or no knowledge of what goes on with respect to child death reviews in the province," said Norm Bossé, New Brunswick's appointed child and youth advocate.
Consider the tragedy of 13-year-old Mona Sock, who died in 2007.
After reviewing Mona's death, the committee told the public there should be better guidelines for background checks on foster parents.
What the committee did not tell the public — but which CBC News has learned from legal documents and interviews with her family and the province's former child advocate — is that Mona lived in a foster home with a convicted sex offender, while under the supervision of a First Nations child welfare agency. It appears that no one did a background check on him.
That man, Lonnie Francis, sexually abused her.
On the day her abuse was revealed to police, Mona hanged herself behind the recreation centre on Elsipogtog First Nation.
By government policy, stories like Mona's stay hidden.
But it wasn't meant to be that way.
Left to die
The provincial government created the child death review committee in 1997, when New Brunswickers were still reeling from the death of two-year-old Jacqueline Dawn Brewer in Saint John.
Inside a dark, dingy apartment on one of the city's busiest streets, Jackie lay dead in her crib for nine hours before anyone noticed. She spent most of her short life inside that crib, never learning to walk or talk.
Doctors determined Jackie's Dec. 17, 1996 death was caused by dehydration. She hadn't had anything to drink for days.
Her parents had been the subject of 16 child protection referrals, including one from the girl's aunt, who warned Jackie's life was at risk. Still, she wasn't saved.
Jackie's parents, Marc Janes and Helen Brewer, were convicted of manslaughter and sentenced to three years and nine months in prison. An angry crowd gathered outside the old Saint John courthouse on the day of the sentencing.
Throughout the province, people were asking the same question: How could a child die in plain sight?
That question led to the creation of the committee — tasked with reviewing the deaths of children in care, or whose families were known to the Department of Social Development. The goal is to prevent future deaths and improve services to children.
Made up of experts such as doctors, social workers and lawyers, the committee reports to the chief coroner who issues press releases, case by case, that include its recommendations. These releases lack context, however.
Committee reports then go to the Minister of Families and Children, who issues another statement, responding to the committee's recommendations.
But the responses are often vague and rarely promise action.
A 2010 release from the coroner, about the deaths of two children, recommended more "proactive supervision" in cases where children are being abused, for example.
But it didn't reveal how the children died or if they were abused.
The minister responded by saying New Brunswick's child welfare system already takes a "proactive approach to preventing child abuse."
And that was the end of that.
'This is not about secrecy'
Since 1997, there have been 136 deaths referred to the child death review committee.
Of those, 78 children died from natural causes, such as cancer, according to statistics provided by the coroner's office.
At least 53 children died from what the committee has classified as "other." That could be anything from suicide to neglect to a car crash.
CBC News has made three separate freedom of information requests over the past three years to try to access copies of child death reports.
The provincial government has withheld the full reports, citing privacy legislation. Instead, it sent some 40 pages of undated recommendations and, later, press releases that had already been issued.
Elaine Bell, a spokeswoman with the coroner's office, said the reports are confidential "advice to minister."
A person's cause of death is considered private health information under New Brunswick law, she said.
"This is not about secrecy," Bell said in an emailed statement. "This is about protecting the private, personal information of individuals which is required by law."
No one is responsible for following up to make sure change happens after a child dies.
And no one will talk publicly about the deaths.
'Buried with those children'
CBC News requested interviews with Minister of Families and Children Stephen Horsman, Justice and Public Safety Minister Denis Landry and every member of the child death review committee. No one would agree to be interviewed.
A producer tracked down Horsman at an unrelated public event and asked him how much the public should know about child death reviews.
"To be honest with you, I'm not sure the general public is aware of that or is wanting to know that information," he said.
The Progressive Conservatives and Green Party Leader David Coon are calling for the government to release more detailed child death reports to the public.
Dorothy Shephard, the Opposition critic for families and children, said privacy is important, but the public needs to know why recommendations are being made.
Both parties question whether the child death review committee is doing the job it was set up to do.
"It's really a scandal that the circumstances around children's deaths, the recommendations of the child death committee, all of that is just buried with those children," Coon said.
Watchdog wants more transparency
New Brunswick's child and youth advocate also doesn't buy the government's argument.
Norm Bossé is one of the few people outside the coroner's office with the power to look at child death reports.
If privacy is the issue, he said, the substance of a report could be made public without the name of the child who died.
"To say that this is private information, I really don't understand their argument there. I certainly don't subscribe to it."
He said the public should know how many children are dying and how they're dying.
"It's the last look, frankly, at what happened to this child," Bossé said.
"If it's a preventable death, the society, the people in this province, have the right to know how can we prevent that."
'Needless, shameful loss of life'
His views are shared by Sherry Bordage, Jackie Brewer's aunt.
In 1996, after Bordage visited her brother's home, she warned social services about the condition of Jackie and her equally pale, thin siblings inside.
"The next day, when I spoke to the Department of Social Services officials, I said, 'I fear for her life,'" Bordage told CBC News recently.
"This was a completely unnecessary and needless, shameful loss of life."
Bordage, who grew up in the foster care system herself, fears that people have forgotten the horror of Jackie's death and that nothing has changed.
She worries there will be another Jackie unless the child death review system becomes more open.
"Silence is continuing to help a broken system continue the status quo," Bordage said.
"I think the only way to really change any of this is real transparency."
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