A report the Newfoundland and Labrador government fought to keep under wraps for years reveals new details about what went wrong in the case of parents who had children removed from their care.
And some of the recommendations in the 2010 report — which has remained under lock and key until a judge finally ordered its release this year — echo similar advice given two years earlier.
CBC News can reveal new details about the situation, after fighting the case all the way to Newfoundland and Labrador Supreme Court.
For years, the provincial government fought against the release of the report.
The government rejected the initial access to information request, and dismissed recommendations by the privacy commissioner that most of the report should be made public.
CBC News took the case to court, and won.
Because of a subsequent change in legislation enacted by the province in 2011, the woman at the centre of the case cannot be identified.
Neither can any details about the families involved in the investigation.
The judge who ruled that a version of the report should be released specifically warned CBC News against doing so.
Some of the report is blacked out. But there is significant detail in what was released to outline some of went wrong in this case.
“It was clear from the whole process that people weren't clear in their roles and that led to considerable delays in our case,” the woman, who CBC News is calling Ms. X, said.
Her lawyer has stronger words.
“Our clients certainly feel as if the system failed them,” Don Anthony told CBC News.
“It was slow in its redress of their situation. Very fast to create the situation but very slow to fix it.”
Several problems identified
The consultant hired by the government said that even though all the systems involved in this complex case tried to work together, there were a number of problems.
- "sharing of information and disclosure of records";
- a "lack of formal documentation" such as "minutes" of case conferences which were "central to the case”;
- a "lack of clarity" pertaining to expert medical information.
Anthony would like to have seen less black ink in what was made public. But the lawyer says the report does tell a clear story.
The slowness of the system, according to the consultant, was a direct result of so many public bodies and departments involved in a complex case.
That includes Child, Youth and Family Services, the police, medical experts, and Family Court.
One of the consultant’s eight recommendations was that the department should develop guidelines for "management of complex cases.”
And for "managers and supervisors to complete regular documentation.”
In this case, the review found that reasons for key decisions were "not documented" in the files.
If this all sounds familiar, it is.
Same consultant, similar recommendations
This same consultant wrote a report for Child, Youth and Family Services in 2008 — two years before the report CBC News fought so long to obtain.
The consultant was hired to do a clinical review after the death of Zachary Turner.
Some of her recommendations then are the same — word for word.
- “a system for the management for complex cases is needed";
- “current standards of documentation are a serious concern throughout all of the programs.”
“There was reference to lessons learned that they should have, they dealt with this before,” Ms. X said.
“They never learned from their mistakes and they continued to make mistakes in our case.”
For her lawyer, this report raises another important issue.
Child Youth and Family services set the parameters of the review quite narrowly — excluding those most affected by it.
'The families were never interviewed and that strikes me as odd. That's like somebody doing a review of the treatment I received at the hospital and talking to the doctors, the nurses, the anesthesiologist, the ambulance driver, the 911 operator, everybody but me.' - lawyer Don Anthony
“The families were never interviewed and that strikes me as odd,” Anthony said.
“That's like somebody doing a review of the treatment I received at the hospital and talking to the doctors, the nurses, the anesthesiologist, the ambulance driver, the 911 operator, everybody but me."
Ms. X wanted the opportunity to tell the consultant how her life was turned upside down.
She says her family are still living the effects of what happened to this very day.
“My children are still feeling the effects emotionally, like even to this day our oldest child is there and he says, if I go to go out or something, ‘Mommy, are you coming back.’ And it’s hard.”
She wonders why her family should have had “to suffer because of a failed system.”
Report not critical of social workers
The report is not critical of social workers involved in the case.
The consultant says the social workers made considerable efforts to gather information and to understand it.
Instead, the issues that arose were systemic and came from decision-makers above the level of the front line staff.
The Department of Child, Youth and Family Services said the minister was not available for an interview Tuesday.