A damning report: part one

On February 7, 2020, as headlines around the world – and many of us — were preoccupied with the early days of COVID-19, Jennifer Kagan reluctantly sent her four-year-old daughter, Keira, off for her scheduled time with her father.

Reluctantly, because after almost four years of fierce litigation in which Jennifer had told the court again and again about the abuse she had been subjected to by her husband as well as her serious concerns about Keira’s safety when she was in his care, he continued to have frequent, lengthy and unsupervised time with her, as ordered by the family court.

Her reluctance was well founded: two days later, on February 9th, Keira and her father were found, dead, at the bottom of a cliff in Rattlesnake Point conservation area, near Milton, Ontario.

As tireless as Jennifer was during Keira’s life in her efforts to keep her safe, she has been even more so since her death, calling for accountability on the part of the systems that so clearly failed her and her daughter and advocating for changes to the law and legal processes so other mothers and children can have happier endings to their stories.

Two of the many accountability measures Jennifer called for were for Keira’s death to be reviewed by Ontario’s Domestic Violence Death Review Committee and for an inquest to be held into the circumstances of her death. On the eve of the third anniversary of Keira’s death last week, the DVDRC report was released, and the coroner announced there would be an inquest. A second report, one focused on the child protection response, has also been produced.

The DVDRC report is heartbreakingly damning. It’s powerful and painful reading for an outsider. I can’t imagine how Jennifer must have felt when she read it, although it provides clear vindication for what she has said since the beginning of her case.

As she said in a text exchange we had last week:

“It hits the bullseye. . . .It’s a really good report. We are happy with it. . . The system is rotten.”


The report begins with the committee’s conclusion that the deaths of Keira and her father “are extremely consistent with past reviewed cases involving intimate partner violence and, in particular, past cases of murder-suicide involving a father and child. . . . The information is more consistent with this pattern than an accidental fall.”

The report notes that the deaths may have been part of the father’s retribution against the mother for leaving him, entering into a new relationship and having a child in that relationship.

This is a trap in which women find themselves again and again. When they stay with an abuser, they are criticized for not leaving, and their stories of abuse are often greeted with comments like “If it was that bad, then why didn’t you leave?”

But leaving the abusive partner escalates the risk of lethal violence. The abuser, unable to accept that the relationship is over, takes an “if I can’t have you, no one will” attitude, which justifies – to him – the killing of his former partner. Sometimes that need for retaliation turns into “I am going to take what you value most,” to justify – to him — killing a child or children.

Some women stay and remain subjected to abuse by their partner, because this feels safer than leaving and entrusting their safety and that of their children to a very flawed family law system.

Other women – think about Saskatchewan’s Dawn Walker – leave and, when the family law system fails them, they take matters into their own hands. This can lead to outcomes like Dawn’s: she now faces multiple criminal charges for “abducting” her child, who has been placed in the care of the father she sought to protect them from.

Jennifer made the decision to leave and followed the rules, dealing with both family court and child protection systems that denied the seriousness of the abuse and the very real risks faced by her daughter, leading to the most tragic outcome possible.

Women, and often their children, are damned whatever they do.

A liar and worse

The family court found that Keira’s father had an “unfortunate propensity to lie,” and lie he did: about his education, about what degrees he had obtained and from what academic institutions, about being sexually assaulted while a university student, about having Indigenous heritage and about online intimate relationships he had. Former partners provided evidence about his emotional abuse, which he denied. He denied his abuse of Jennifer. He made fraudulent representations to the court.

On at least five occasions, he took Keira without consent and outside the terms of the interim parenting agreement or refused to return her when the agreement required him to do so. The police and three different child protection authorities were involved with the family on a number of occasions.

The case appeared before at least 10 judges. When there is not one judge keeping an eye on the details, important realities — like patterns of coercively controlling behaviour, for instance — can slip beneath the surface and get missed, creating additional risks for the survivor and children.

Over an almost four-year period, Jennifer and her ex-husband were in court dozens of times, and more than 50 decisions were issued by the court.

What may be the most troubling is that, even when one judge acknowledged that there had been IPV during the marriage, he denied that it had any bearing on the father’s ability to be a good parent. Another noted the father had demonstrated that he had “an aggressive and somewhat bullying approach to the [mother] and to third parties,” confirmed that he had lied in his court documents and said he had characteristics that would not make him a good choice to have responsibility for making decisions related to Keira’s upbringing. Still, this did not have an impact on his decision about parenting time.

Escalating risk factors

The DVDRC has identified  41 factors that indicate a case is high risk for lethality. Where there are seven or more factors, the committee deems the death to be both predictable and preventable. In this case, the DVDRC identified 22 risk factors, including:

  • End of the marriage
  • An ongoing custody dispute
  • A demonstrated failure to comply with authority
  • Misogynistic attitudes
  • History of IPV with previous partners as well as with Jennifer
  • Prior incidents of forcible confinement by the perpetrator
  • Prior choking and strangling
  • Violence against family pets
  • Extreme minimization and denial of his abusive behaviour
  • Continued access to the mother and child after the risk assessment

And yet, Jennifer and Keira had to live with a parenting order that gave the perpetrator three days and nights of unsupervised time with Keira every week, while Jennifer had sole responsibility for all decision making; surely a situation that could only lead to greater trouble.

In the weeks and days immediately leading to Keira’s death, that greater trouble arrived: according to the DVDRC report, “matters appeared to be reaching a crisis point.” Even more high-risk factors emerged.

The police were called to assist with a return of Keira to her mother’s care because her father would not release her. The family court asked the child protection agency to complete an updated assessment related to risk and raised the potential of reducing the father’s parenting time and/or limiting him to supervised visits because of his escalating erratic behaviour. The child protection worker indicated they had serious concerns about continuing with unsupervised parenting time and said they were going to report this to the judge.

Astonishingly, the father was given an opportunity to view the file that contained these concerns just prior to the fatal weekend. That same worker, on the Friday before Keira’s death, said they were considering making an application for a protection order, but would not be discussing that with their supervisor until after the weekend.

As the report reads:

“The mother in this case told the court and the Children’s Aid Society that she was concerned that the father would harm their daughter prior to the fatal weekend visit, the Children’s Aid Society worker expressed concern that the father was displaying signs consistent with the behaviour of someone who may harm their children.”

And yet, Keira’s scheduled weekend with her father was to take place.

Stay tuned for part two, which will look at the child protection response and recommendations for change.

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