Madison's short, unhappy life among 22 suicides of girls outlined in new report

The stories of 22 Manitoba girls who died by suicide from 2013-19 that are profiled in a new report from the children’s advocate are a portrait of the gaps and barriers young people face in the province while trying to get support.

Children's advocate says suicide is leading cause of death in young people in Manitoba

The children's advocate says suicide has become the leading cause of death for youth in Manitoba. (Costea Andrea M/Shutterstock)

Madison asked for help many times in her life but after years of failing to find support from her Child and Family Services caregivers, she killed herself when she was 15.

The girl — Madison isn't her real name — is one of the sad stories in a 101-page report on the suicides of 22 girls age 11 to 17 who died in Manitoba from 2013-19.

The report, named Stop Giving Me a Number and Start Giving Me a Person, was released by Manitoba Children's Advocate Daphne Penrose on Thursday morning.

It makes seven recommendations to better support young people in crisis, including identifying gaps in mental health and addictions support for youth and ensuring equitable access to those services.

An example of the failures of Manitoba's system is detailed in the life of the girl the report calls Madison, who was first involved with Child and Family Services shortly after birth, but repeatedly failed to find the help she needed and asked for.

The advocate's investigation into Madison's death found questionable decision-making by the agency responsible for her life, including a lack of follow-up when counselling was offered and leaving her in a home other children were removed from, and where she felt unsafe.

"Madison's early-childhood trauma was not recognized by the CFS agency involved, nor did the agency act protectively towards Madison, despite the agency's legal and ethical responsibility for her care, protection, and development," Penrose says in her report. 

Removed from foster home

Like many of the 22 girls profiled, Madison was able to access mental health supports when in crisis but wasn't supported with followup or resources after.

Those who knew Madison say she was a compassionate girl, the report says.

She lived in rural Manitoba and was a permanent ward of a Child and Family Services agency when she died.

Her involvement with CFS started shortly after she was born. Her parents had addictions issues and there were allegations of child neglect. She entered into CFS care four times by her fourth birthday.

Manitoba Children's Advocate Daphne Penrose's new report shines a light on the circumstances leading to the suicide deaths of 22 Manitoba girls. (Austin Grabish/CBC)

The report says when Madison was five, authorities removed her from a foster home due to allegations of physical abuse.

A psychological assessment found her cognitive ability to be low and recommended she receive counselling to help her combat her sadness, anger and frustration. The advocate found no evidence Madison got counselling.  

Multiple concerns about foster home

She became a permanent ward of a CFS agency when she was eight, at which time she started to say she was lonely and wanted a connection to her biological family. 

Madison's peers were removed from her foster home after concerns were raised about the caregiver abusing alcohol, the condition of the home and physical abuse of kids who lived there. 

But Madison's CFS agency kept her in the home until it was investigated two more times. She was returned to the home by the agency four times over five years despite repeatedly asking to be moved and saying she felt unsafe. 

Eventually Madison ran away and refused to return to the home.

When she was 13, she said she was suicidal and thinking of self-harm. A suicide note was found in her belongings.  

Sexual abuse

A mobile crisis service assessed her and learned she had been sexually abused in a foster home when she was five. 
Madison had disclosed the abuse to a previous foster parent, but that person didn't believe her and failed to report it, the report says.

Following Madison's abuse disclosure, charges were laid against two people.

The teenager continued to have suicidal thoughts and tried to act on them while struggling to cope with the death of a sibling and a friend, trauma and bullying in her school and her foster home. 

A community mental health program received a referral for the teen twice but was unable to engage with her. 

In the last six months of her life, Madison fell into a deeper crisis. 

She missed school and abused substances, and on one occasion police found her unconscious from intoxication and suffering from hypothermia. 

She continued to say she was going to kill herself, but health staff decided she didn't need a psychiatric admission.

No followup

On her final discharge from hospital, staff recommended Madison receive a psychiatric consult, connect with a mental health nurse and contact local crisis resources if she were to feel suicidal again.

A mental health worker tried six times to connect with the agency responsible for Madison's life to make sure she had support, but services were never arranged. 

She died one month later.


Penrose's report makes seven recommendations to the province: 

  1. Conduct a gap analysis on youth mental health and the addictions system.
  2. Demonstrate equitable access to youth mental health and addictions services.
  3. Train workers on trauma and its effects.
  4. Help families learn where the right resources are.
  5. Create more youth hubs.
  6. Create mental health focal points outside Winnipeg.
  7. Create a long-term treatment resource for youth.

From April 1, 2018, to March 31, 2019, 32 children, youth and young adults under the age of 21 died by suicide in Manitoba, the report says.

Since September 15, 2008, 159 children and youth age nine to 17 have died by suicide in the province. 

Suicide has become the leading cause of death for youth in Manitoba, the report says.

Health Minister Cameron Friesen said the recommendations will be considered by government.

"We are committed to working together with organizations, communities and families to help improve the lives of our children and youths," he said in a prepared statement.

The province has made more than $25 million in investments to improve timely access to mental health services for children and youth, Friesen said.

The investments include $4.2 million spent on child and youth mental health assessment and treatment at Health Sciences Centre's children's ER to respond to youth suicide, he said.

MLA Bernadette Smith, the NDP critic for mental health, said the province needs to address the root causes of trauma such as poverty, housing and food security.

Liberal Leader Dougald Lamont said the report is an indictment of years of failure by NDP and PC governments alike to provide mental health care to children. He wants psychological therapies to be included under medicare.

"Mental health care is health care. It's not enough to talk about mental health, it's time for governments to make sure that people can get mental health care when they need it. It will save lives," Lamont said in a release.

The advocate has previously called on the government to establish a long-term residential facility for youth mental health treatment and improved access to treatment for youth experiencing mental health crises.

If you're experiencing suicidal thoughts or having a mental health crisis, there is help out there. Contact the Manitoba Suicide Prevention and Support Line toll-free at 1-877-435-7170 (1-877-HELP170) or the Kids Help Phone at 1-800-668-6868. You can also text CONNECT to 686868 and get immediate support from a crisis responder through the Crisis Text Line, powered by Kids Help Phone.


​Austin Grabish is a reporter for CBC News in Winnipeg. Since joining CBC in 2016, he's covered several major stories. Some of his career highlights have been documenting the plight of asylum seekers leaving America in the dead of winter for Canada and the 2019 manhunt for two teenage murder suspects. In 2021, he won an RTDNA Canada award for his investigative reporting on the Canadian Museum for Human Rights, which triggered change. Have a story idea? Email: