The social services system in Newfoundland and Labrador failed a 13-month-old boy, whodrownedalong with his mother in a 2003 murder-suicide, a review has found.

Zachary Turner died when Shirley Turner, 42, clutched him to her body andjumped intoConception Bay, several kilometres outside of St. John's.

"Nowhere did I find any ongoing assessment of the safety needs of the children," coroner Peter Markesteyn, referring both to Zachary and Turner's daughter from another relationship, wrote in a three-volume report released Wednesday.

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Shirley Turner with her son Zachary: A child death review has found that officials gave more consideration to her needs than to his. ((CBC))

Turner, a general practitioner,fled to Newfoundland after her estranged lover AndrewBagby, 28, was shot to death in a Pennsylvania parking lot on Nov. 5, 2001.

Turner had obtained bail from the Newfoundland Supreme Court, and gave birth to Zachary,Bagby's son, while fighting extradition to the United States to stand trial for the murder ofBagby. About twomonths beforethe murder-suicide,a judge cleared the way for Turner's extradition.

Responding to Markesteyn's child deathreview, Community Services Minister Tom Osborne said the provincial government accepted the report and would examine the29 recommendations to see which ones could be acted on immediately.

Headded thatthe province had already addressed someof the issuesraised by Zachary's death.

Serious flaws pinpointed

Markesteyn, based in Winnipeg, found fundamental flaws throughchild protectionsystem that dealt with the Turner case in the months leading up to the murder-suicide.

In findingthat Zachary's death could have been prevented, he determined poorcommunication between officials contributed to the sequence of events that triggered the tragedy.

Darlene Neville, Newfoundland and Labrador's child and youth advocate,called immediately for an externalreview of the child, youth and family services program.

Neville, who said she is concerned that other children in the province are in similar circumstances, described the results of the investigation as shocking.

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Shirley Turner was fighting extradition to the U.S. to stand trial for the murder of Andrew Bagby, Zachary's father. ((CBC))

"The fact that a whole organization could be so out of touch with the reality everyone else was wondering about is baffling," she told reporters.

Neville said two things were evident from reading the report. "One: Zachary Turner's death was preventable. And two: Zachary was in his mother's care when he should not have been."

Markesteyn found that officials, who were working on the presumption of Turner's innocence,were more concerned about the welfare of the woman than for her infant.

Turner frequentlyasked for, and received,help from social workers, with dozens of visits made on her behalf.

Neville said she found it difficult thatno one was putting Zachary's interests first.

"Given the amount of resources that were put in to meeting Dr. Shirley Turner's needs and demands, and what she identified as necessary, if those same resources had been taken and put in to assessing what Zachary's needs were and how could his rights would be best protected, I would suggest there would be a strong likelihood we would have had a different outcome," Neville said.

Markesteyn, who was asked to review the case in 2005,could not delve into an issue pressed by the Bagby family: how Turner was able to obtain bail from the Newfoundland Supreme Court.

Courts beyond mandate

David Bagby, Zachary's grandfather, said the report is an important step but he is disappointed the issue of the bail processcould not have been addressed thoroughly in the review.

"My focus is bail," he said adding thata suspect in abrutal crime shouldn't be "walking around free so they could do it again. I've said it a hundred times."Bagbytravelled from California forthe release of the report.

Markesteyn nonetheless raised question after question about how bail was granted to Turner, particularly about the actions of federal government counsel.

As well, herecommended that a separate review of the justice system's handling of the casebe launched.

Withthe social services system, Markesteynsharply criticized a lack of critical analysis and sound judgmentamongofficials who dealt with Turner while she was on bail.

Markesteyn found that social workers worked co-operatively with the review and that "the impression they conveyed was they believed they had done everything they could, given their legislative and policy mandate, to assist the children's mother, Dr. Turner, in caring for her children."

'An obvious difference of opinion'

He alsonoted"an obvious difference of opinion" between case workers and their managers, who recognized a possibleneed for long-term intervention. Their concerns, he wrote, were not communicated to frontline staff.

Turner's daughter, who stayed with her mother for periods of time during which she was on bail, also suffered in terms of her educational development, as well asfrom guilt over her mother's and half-brother's deaths, Markesteyn said. The girl is in the care of other family members.

As well, hefound a lack of accountability within the social services system.

"Yes, individuals were upset and sad when Zachary was murdered, but what was really confusing was the limited sense of accountability in terms of the hierarchy and lines of authority," he wrote.

Markesteyn also critiqued the office of the child and youth advocatefor its handling ofTurner's case while she was still alive. He suggested an intervention shouldhave been made.

"To me, it is most relevant that there had been considerable media exposure and resulting knowledge of the Pennsylvania criminal charges whichDr. Turner was facing," he wrote.

Met at medical school

Turner had been married twice before meeting Bagby while both were medical students at Memorial University in the 1990s.

Markesteyn's research,which involved interviews and reading scores of documents about Turner,found numerous cases indicating that shehad personality and emotional problems, including during her medical training at Memorial.

A supervisor there described her as "putting on a show" for superiors, and found she was confrontational, manipulative and unwilling to address negative evaluations. Markesteyn noted that the Turner experience led to changes in how residents are evaluated.

Among other things, the report found Turner had ingested drugs in either an attempted suicide or what Markesteynsaid could have beena "suicide gesture." In a 1999 letter sent to a would-be paramour before she ingested prescription drugs, she described herself: "I am not evil, just sick."

Markesteyn also found that Turner had been under the care of at least four psychiatrists during her lifetime.