A damning report (part two)

Last week, I wrote about the report prepared by the Domestic Violence Death Review Committee (DVDRC) into the 2020 death of four-year-old Keira Kagan. Another report, prepared by child protection expert and Toronto Metropolitan University professor Kim Snow for the Child and Youth Death Review and Analysis Unit, focuses on the actions (and inactions) of the child protection authorities involved with Keira and her family. Its contents may be even more damning than those of the DVDRC report.

Snow reports that, despite years of child protection involvement, Keira’s voice is almost entirely absent. Noting that the Child, Youth and Family Services Act — the legislation governing child protection agencies in Ontario — sets out in section 1 that “[t]he paramount purpose of this Act is to promote the best interests, protection and well-being of children,” she writes that services should focus on the needs of the child, but:

“Notably absent in this case is the voice and perspective of the child.. . . this was a child seen by numerous advocates, yet [was] unheard. . . ”

Failing to put the pieces together

Keira, by all accounts a bright, happy and social child, nonetheless struggled with anxiety, had a variety of unconnected health ailments, had trouble sleeping when she was at her father’s house and, when with her father, was fearful that she would not see her mother again. She was also exposed to the impact of her father’s abusive behaviours on her mother.

As Snow wrote:

“Here we have examples of a child under 5, with known exposure to Intimate Partner Violence (IPV), repeated examples of her father lying to the court and not complying with the orders of the court . . . and yet, the risk profile outlined within the child protection file does not appear to bring forward the cumulative risk, nor the prolonged and multiform exposure that the child was experiencing .. . . . Despite the child requiring treatment for distress and self-regulation during and post access/parenting visits, there is no direct intervention to reduce the potential risk the child was facing.”

According to Snow, “The protection needs of the child do not appear to be paramount, her well-being does not appear to have been scrutinized, and the best interest assessment seems to be deferred to the courts.”

The report sets out in some detail the events in the days immediately prior to Keira’s death, some of which I discussed in last week’s post, but this report looks at them specifically through Keira’s lens, noting that the child is the primary service recipient in child protection cases.

It is critical of the lack of follow-up with her about concerns she raised and of the fact that the CAS did not conduct a renewed risk appraisal.

Lethality risk factors

Snow also comments:

“Despite the child being directly involved in the conflict, there does not seem to be any safety planning conducted directly with the child. . .  . it is surprising that an order for supervised access was not contemplated. . . . The impact on the child, and her emotional distress, resulting from prolonged conflict, needed to be assessed as a form of child abuse.”

She identifies 15 lethality risk factors, many of which are the same as those identified by the DVDRC. Additionally, Snow’s report lists:

  • Assaults on Jennifer while she was pregnant
  • Obsessive behaviour by the father
  • The presence of step-children
  • The father’s concerns about a potential and imminent loss of parenting time
  • The presence of coercively controlling behaviour by the father

Whichever list you want to look at, there were multiple undeniable and identifiable risk factors. Yet, the child protection authority—whose mandate is to protect children from harm – did nothing to stop Keira’s father from having unsupervised time with her even, when it had acknowledged that his time with her should likely be reduced and/or supervised.

But it was a Friday, and all that could wait until Monday, so the weekend visit proceeded. By Monday it was too late.

What now?

Both the DVDRC and Snow reports make a number of recommendations. One of the common themes is the need for more training.

The DVDRC wants to see more training for the CAS, judges, lawyers and mental health professionals who complete parenting assessments, with a focus on understanding the differences between coercive control/litigation abuse and conflict as well as understanding the implications of family violence in parenting plans that promote safety for the child and mother.

It calls for mandatory professional development opportunities to enhance judicial understanding of the dynamics of family violence including coercive control and the implications for parenting and children’s well-being, such programs to be developed with “experts in the field.”

There should be, says the DVDRC, mandatory family violence training for lawyers practicing family law and in Law Society bar preparation materials and exams “to reflect that this is a core aspect of necessary competency for lawyers practicing family or criminal law.”

Noting that “[t]here is an uneven approach to pre-service education on family violence across different disciplines,” the DVDRC writes that “the time has come to ensure that every discipline has this critical background information,” and calls for education on family violence as part of the required academic program for law, social work, psychology, nursing and medicine students.

The Snow report focuses on training for the CAS, including recommendations to the lead agency to conduct internal agency-wide IPV training. She recommends that the Ministry of Children Community and Social Services introduce regulations that set standards for pre-service training of child protection workers, fund training for professionals and officials on their duty to report and revise the legislation to explicitly include involvement in IPV that causes distress to the child.

The DVDRC also calls for a one family/one judge case management system “to ensure a coordinated and informed approach” as well as “the use of a systemic early identification system which would identify, for management by one judge, all cases which raise issues of family violence.”

Yes, yes and yes again to all of these recommendations, many of which have been made before. Perhaps this time, they will be taken seriously and implemented without further delay.  

Tomorrow is too late.

2 thoughts on “A damning report (part two)

  1. I was stripped of custody and all access to my soon to be 12 yr old son last year, because the father claimed alienation. We’ve been going to court for 2 yrs, and that was the temp order the judge ordered. My voice as well as my son’s ceased to exist in this case once the word “alienation” was used against me. Despite numerous agencies dealing with my family, none cared about my son’s voice. Section 30 was used to completely remove my child because of the false alienation accusations. The police in my community refused to label our case as DV, and wrote conflicting reports in favour of the father. Many advocates have tried to help us, but the single judge refuses to acknowledge actual facts and evidence. I now have had to resort to having the survivors secretariat and residential school survivors attend court dates in order to be treated fairly. A SWAT team took more than an hour to remove my son who was screaming he was going to kill himself if he had to see his father. He also disclosed that the father sexually abused him and gave a video statement which the police refuse to release to me. I go for trial later this yr, but have been told my case needs interveners and that it is a public interest case because of the accumulation of bias and prejudice against both my son and I.

  2. The only time that victims of domestic violence will be heard is when the laws in Canada change when domestic violence is identified and No-Fault Divorce needs to be thrown out when it comes to light. More credence needs to be given to the victims, in particular children who may suffer from alienation from their only capable parent, suicide, death by the abusive parent, sustain irreparable injuries from the abusive parent, and suffer from future mental health and addiction problems. The courts effectively crazy-make vulnerable victims and legal aid only helps DV victims in final trials and not even with that. So self-representation is a vulnerable victim’s only means to defend themselves in a court system that is set against them in the first place.

    The problem Ms. Cross with all these studies is that their findings and discoveries are never implemented and practiced in the real working world of the justice system. Look at Peter Jaffe’s research for decades on how abusers use alienation against victims and the court still supports the abuser and condemns and labels the victims for causing the high conflict proceedings. The findings are never instituted and are only instituted when the user who determines the outcome decides to institute them.

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