By Barb Pacholik and Karin Yeske, Postmedia NewsREGINA — The grandmother of a three-year-old boy who died in foster care in Saskatchewan is making a tearful plea that his death result in changes so other families are spared from such a tragedy.
"One dies so many will live," said the woman, who cannot be identified under a publication ban.
"This was a preventable death. We pray for all the children in care. This inquest took place to prevent this from happening to other children."
A coroner's jury on Friday night deemed the death of the little boy, who can only be identified as APG, a homicide.
The boy died at a foster home in Pense, Sask., on Dec. 17, 2009, after suffering what the inquest this past week heard was a chest infection that would have been treatable had he received medical attention.
The case is the latest in a seemingly endless trail of child injuries and deaths that have raise concerns and drawn outrage over the quality of foster care across Canada.
The coroner's inquest focused in great detail on the state of the foster home, which was cluttered and unsanitary, and had often seen children fall down stairs.
While the jury deemed the boy's death was homicide — defined as the result of a voluntary act to cause fear, harm or death — it had inquired early in the deliberations where negligence fit.
Presiding coroner Alma Wiebe said homicide, as defined by the Coroner's Act, does not include acts of omission, and if the death doesn't fit into the categories, it's undetermined.
The jury returned with seven recommendations, directing Saskatchewan's Ministry of Social Services to do everything from more thorough foster home checks to making them safer.
Andrea Brittin, executive director for service delivery in Child and Family Services, said the ministry respects the process, appreciates the work of the jury and needs time to consider its findings.
"The death of this child is indeed a tragedy," she said, extending sympathy to the boy's family and friends.
The boy had been a permanent ward of the province.
A pathologist found he died from a treatable bacterial infection that started with bronchial pneumonia and spread to his chest cavity.
In her final instructions to the jury, the presiding coroner noted the pathologist was unable to directly link the chest infection to the conditions in the home, but she added that the jurors may infer that the state of the home raised issues of quality of care and neglect.
The jury's final recommendations include improving foster-home checks and closer monitoring by case workers and supervisors.
They also call for improved training for foster parents and ensuring that children with medical needs are placed in areas with adequate medical facilities.
Bob Hughes, who represented the boy's biological family in the inquest, said action hasn't always followed the recommendations brought down inquests.
"I think the value of this inquest is yet to be seen in what changes the ministry is able to do."
APG and his sister joined another foster child and three adopted children in the home in June 2009.
The inquest heard that child-protection workers were raising concerns with the resources unit, which was responsible for the home, about the deplorable and deteriorating conditions for over four months before APG died there.
Some measures were put in place, but they didn't happen fast enough. In November, the home failed a safety check.
It was only after the boy's death that a comprehensive review of 31 files on the home since it opened in 1999 revealed a pattern of concerns regarding quality of care and conditions. But no one person had that complete picture until the death, the inquest heard.
After the boy's death, three adopted children and one foster child remained in the home because conditions improved.
But by March 2010, things had deteriorated again and all the children were removed and placed in foster homes. In August, after court action, the adopted children were allowed to return, but under terms, including increased checks and counselling for the children and parents.
Child protection worker Holly Murray testified she was at the home Dec. 30 and "it has improved greatly."
"There is still some clutter, but no safety concerns," she added.
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