Lynn Moore, a lawyer with a specialization in childhood sexual abuse, doesn't believe anyone should be fired for the mishandling of a child abused by her stepfather and twice impregnated.
She doesn't believe anyone should be fired for the abortions either — the first at just 12 years of age, which happened in Newfoundland and Labrador.
But Moore does have an idea for what the provincial government should do.
"Hire 400 people," she said. "Hire a massive army of social workers who will help protect our children in this province."
On Wednesday, the province's child and youth advocate Jacqueline Lake Kavanagh released a report detailing the story of the young girl.
For 26 months she was sexually assaulted by her stepfather, whom she believed to be her biological father.
At age 12, the girl went to Planned Parenthood for an abortion. She said she was impregnated by her boyfriend. The stepfather said he was her guardian. She was referred to the local health authority for the procedure to be provided.
Nobody asked how old her boyfriend was.
Nobody asked if the man was her legal guardian.
Nobody offered appropriate counselling for her.
"If a 12-year-old is pregnant then that's a pretty serious situation that requires some outside help," Moore said. "There should have been a wraparound of supports, not just the provision of a service."
Stint in province short-lived, but full of problems
The family lived in Newfoundland and Labrador for five months, during which time they were involved with every institution dealing with child protection.
Two years after they left, the daughter told police about her stepfather's history of abuse. By this time, she had endured the second abortion of a fetus he had fathered through rape.
The man was sentenced to 16 years in prison.
During their stay in Newfoundland and Labrador, the Department of Children, Seniors and Social Development (CSSD) was involved with the family.
'I felt sick to my stomach. I felt really sad and disappointed.'
- Rolanda Ryan, Athena Health Clinic
The department received three referrals — two for lack of supervision and one claim of the father physically abusing the children.
The 12-year-old girl was eventually interviewed by CSSD staff at her school. The stepfather had become uncooperative and hard to locate, the report said. Four months later, it was learned they had left the province.
According to Kavanagh's report, CSSD did not complete child welfare or criminal background checks on the man.
The department contacted child welfare officials in the other province before closing its file on the girl.
Major questions not asked, says private clinic manager
When Rolanda Ryan heard about the case on Wednesday, she was gutted.
"I felt sick to my stomach," she said. "I felt really sad and disappointed."
As the manager of Athena Health Clinic, the province's only private abortion provider, she has seen plenty of young girls come for help — but rarely under the age of 14.
At the tender age of 12, the girl's situation should have raised red flags at every step of the process.
"I wonder where it fell apart," Ryan said. "At what point did they not ask the right questions?"
'The emotional impact ... is horrific.' - Rolanda Ryan
The Athena Clinic was not involved with the girl in the report. If they were, the outcome could have been totally different, Ryan said.
A social worker counsels each young woman who comes to Athena for an abortion, before and after the service is provided. The counselling occurs without anyone else in the room.
If something seems off, the case is reported to proper authorities, Ryan said.
"Anybody we have that's young, we go over and above trying to get as much information as we can at every step."
What happened to the girl?
Both Moore and Ryan worry about what became of the young girl in the report.
Her stepfather cannot hurt her anymore, but how will the memories of 26 traumatic months haunt her as she goes forward in life? How will two abortions before the age of 15, resulting from torment by a man she should have been able to trust, affect her health?
"I think the emotional impact of being abused alone is horrific, but then to have such an invasive procedure performed," Ryan said. "I'm sure she feels let down by the system that was set up to protect her."
Moore believes the young woman will need a lot of therapy, but said youth who suffer sexual abuse can still overcome it.
"That's what I hope for her. I hope that she is ready to talk about it, and I hope there are trauma-informed people ready to talk to her."