Nova Scotia's acting ombudsman has identified several shortcomings in the way the province dealt with the case of a toddler who died four years ago after authorities were alerted to concerns about his well-being.
CBC News has confirmed the review centres around Antonio Ryland Pinch, a two-year-old boy who developed stomach pains and then died at his North Kentville home on May 8, 2010.
Adam William States was charged with manslaughter in the boy's death and was acquitted in 2012.
Christine Delisle-Brennan, the province's acting ombudsman, issued a report on Tuesday recommending the province set up an independent team to investigate all deaths and serious injuries involving children receiving government services.
She wrote there were vague standards and her office's investigation highlighted a "fragmented" government approach in how Child Protection Services handles referrals.
Her report said there were problems with vague standards, poor communications, inadequate record keeping and heavy caseloads at the Department of Community Services.
Before Antonio's death, the Child Protection Services division of the Department of Community Services was involved in the boy's case several times.
"There was a series of five referrals or complaints to Child Protection Services expressing concerns about the child's well-being. Two separate investigations remained open when the child died," read the report.
The investigation into the child's death involved a number of government departments, including the departments of Community Services, Health and Wellness and Justice.
'Series of disconnects'
Delisle-Brennan concluded in her review that there were "communications issues and some vague standards" among government departments, leading to the tragedy.
She said the investigation did not turn up evidence of government agents or public servants acting in "an uncaring or indifferent manner" or any specific actions or inaction by them that resulted in the child's death.
"Rather, it revealed a series of disconnects, issues related to standards and uncertainty of approach. What emerged from our investigation might best be described as system fragmentation," she said.
"The intended outcome was not to ascribe blame, rather to independently examine government services in relation to a specific child death."
Delisle-Brennan's office also discovered the partner of Antonio's mother had been the subject of another child protection case, but never ran his name through their computers before the child's death. Delisle-Brennan said she's troubled by that.
"There was information in the child protection records that although wasn't specific to this case, we questioned whether if child protection workers had that information, whether that would have perhaps altered their investigative plan or the timeframes of when they interviewed certain individuals," she said.
Boy died of blunt abdominal trauma
The person responsible for child welfare in Nova Scotia said there's nothing more officials could have done to protect Antonio.
"We were looking at whether or not the children were adequately supervised in the family and that's not a predictor of violent behaviour," said Vicki Wood, the executive director of children and family services for the Department of Community Services.
"There hadn't been physical abuse or assault. But the bigger question is, how well can practitioners identify risk and is it a 100 per cent accuracy kind of situation? And it isn't."
The investigation also found sharing of information between health-care personnel and child protection staff was hampered by legislative requirements, the sensitive nature of health information and database differences.
"Throughout this investigation, this office observed … health-care professionals invoke confidentiality as a barrier to sharing information," the report said.
Delisle-Brennan's report left out the boy's name, age and sex, but revealed an autopsy found that Antonio's death was caused by blunt abdominal trauma.
According to the report, the toddler had an older sibling, who was taken into care after Antonio's death.