Canadian Fatality Inquiry-Samantha Martin case UPDATED

One thing that I would like the general public  (and even adoptive parents and prospective adoptive parents) to understand is that sometimes parents of disabled children really are intimidated to releasing their child to state care. Like many biological families in other countries, this biological family would visit their child in state care. This case occurred in Canada  and only in 2009 was a law passed to prohibit this intimidation.

“A fatality inquiry into the death of a young girl details a system that  simply failed to act and now the girl’s mother wants changes.

Velvet Martin says she was told her daughter would have severe disabilities  when she was born in 1993 and that in order to get the best supports she should  be in government care.

Martin trusted that decision and her daughter Samantha was put into foster  care.

The Martins had regular visits and eventually they as well as school  officials started documenting injuries Samantha was suffering.

The wounds ranged from bumps and bruises to fractures and bone breaks. The  girl was also well underweight and hovered around 50 pounds between age 10 and  13.

School officials were growing concerned Samantha was suffering seizures.

That’s when Martin began the fight to get Samantha back home. Just months  after that happened in 2006, she died.

“We trusted and that is something that I will always regret,” said  Martin.

She fought for years to have a fatality inquiry performed.

When that finally happened the judge heard testimony teachers noticed the  foster parents’ biological child’s lunches were more balanced. When the school  raised the issue, the foster mother’s response was to tell the school to “fill  Samantha up with water.”

Heath records showed a period of 3 years where Samantha was not seen by a  pediatrician or family doctor despite suspected seizures. Caseworkers didn’t  meet with the child for 14 months.

“There’s a lot of complexities when it comes to child protection but what  this fatality report does is it shows a failure at the most basic of levels,” said NDP MLA Rachel Notley. “Nutrition and health care and following up when the  teacher calls to say I think there’s something wrong.” The inquiry contains  recommendations including:

• Ensuring caseworkers have accurate and up to date information
• Ensuring children are actually receiving annual medical checkups
• When observations about injuries are made by reliable sources that a  medical examination is performed
• Ensuring caseworkers have a reasonable case load

“Beyond policy there needs to be repercussions when policy is not adhered to.  And government employees must not be above the law. They must be accountable to  the law just like everybody else,” said Martin in reaction to the  recommendations.

“It’s hoops that people are jumping through and children don’t have time to  wait, they end up dying,” she adds.
On Friday Human Services Minsiter  Dave Hancock had yet to read the inquiry’s recommendations. His press secretary  Craig Loewen said considerations will be taken.

“Of course, we do take the recommendations and results of these inquiries  very seriously so we will be taking a look at them very shortly here and seeing  what changes we can make,” he said.

No timeline has been given for when those changes would be made but Loewen  said there have been several changes to the system since Samantha died so the  recommendations could be repetitive.

While Martin hopes changes are made, she said there’s one thing she wouldn’t  change.

“I’m very happy to have been Samantha’s Mom. I would do it all over again, as  hard as it has been. But I would do it all over again.”

 

Young girl’s mother hopes inquiry sparks changes

[CTV 10/19/12 by Breanna Karstens-Smith]

“Almost six years after her daughter Samantha died after a long stay in foster care, Velvet Martin has some answers. But according to her, it just isn’t enough.

When Samantha was a newborn, Velvet was told her daughter had been diagnosed with a rare genetic disorder called Tetrasomy 18p and would be mentally and physically disabled.

“The prognosis was horrendous,” she recalled.

Two social workers from what was called Handicapped Children’s Services arrived at her home and told her that the job of raising her daughter was beyond her ability and they couldn’t provide the necessary resources to help.

“You can’t do this,” she remembers them saying to her. “And we can’t provide you, the natural family, with the resources in home that your child is going to need to survive. You need to surrender.”

Samantha went into foster care that day, where she lived until 2006 when her parents decided to take her back. Six months later, Samantha went into cardiac arrest and died.

Her parents claimed her death was in part due to mistreatment in foster care, but no charges were ever laid and a 2007 Children’s Services internal review found no link between the foster home and her death.

Since then, Velvet and Samantha’s father John have pushed for a fatality inquiry into her death. A report from that inquiry was given to them recently and will be released to the public Nov. 2.

“I’m pleased in the respect that some of the facts have emerged in the media at last. That in itself has been an uphill battle to be able to talk, due to publication bans,” said Velvet, having read the report.

The initial battle for her was to overturn a publication ban on Samantha’s name, something she said is meant to protect children but actually protects those responsible for her daughter’s death.

Otherwise, she feels the report says nothing to change the situation that led to Samantha dying.

“All it’s underscoring is the fact that the policies that are in place, the judge has said you really need to do them. They haven’t been doing them all along so what it actually should say is there are repercussions if you don’t do your job,” said Velvet. “I look at it and go, ‘OK, a lot of the truth is revealed but at the same token, nothing has been done.’”

Marilyn Koren agrees.

“To begin with, these people should definitely be charged. They should be charged and face the same punishment as you or I would be facing had we done the same thing. And they are not. Absolutely no one is being held accountable for what is happening to these children. The system is just failing so many children,” said Koren, who works alongside Martin in a group called Protecting Canadian Children.

Koren’s own granddaughter, Delonna Sullivan, died while in foster care and believes it could have been avoided.

According to Koren, Delonna was in her home in April 2011 when children’s services came with an apprehension order for two other children in the residence. They took Delonna as well.

“They just flat out refused to let any family member take her. That social worker just said, ‘No, she’s going into foster care and that’s all there is to it,’” she said.

Delonna died six days later.

Koren says she received her granddaughter’s medical report a year later and found a series of inconsistencies with what she was told a year prior, including a toxicology report that showed several drugs present in Delonna at the time of death.

Because of a publication ban, she says she has been unable to tell her granddaughter’s story and seek justice.

“The ID ban should be lifted because what is happening to our children is a matter of public interest. The way it is right now, as long as these children and families are nameless and faceless, the public has no idea as to really what is going on,” Koren said.

For those wanting justice, she said even the police are not able to access some social services records, making it easy to cover up wrongdoing when it occurs in foster homes.

She said she wants government to rethink how social services is run and plans to continue to push for changes in legislation.

“I don’t want money, I don’t want to sue the government. I just want to see changes,” she said.

Those concerns have been brought to Dave Hancock, Alberta’s minister of human services. According to his staff, the minister is still reviewing the fatality report but they pointed out some signs of forward motion over the past six years.

“It’s never a good thing when someone passes away in care, regardless of the circumstances,” said Craig Loewen Sunday, the minister’s press secretary. “There are some changes that have been made since that time,”

Loewen pointed to a legislation change made early in 2012 that made the child and youth advocate an independent entity able to investigate any case they want to.

Though Martin questioned whether those investigations will actually happen, Loewen said the same doubt can be placed on any level of investigations including those conducted by police.

He also said there are more supports being offered through the family support for children with disabilities program, a program he said has allowed between 95% to 98% of children with disabilities to be able to remain with their natural family.

“That’s not to say that we can’t learn things from the fatality report,” Loewen added. “We’re certainly going to take a look at the recommendations. It’s something we definitely take seriously so there could be further changes.”

 

Report says nothing that would have changed daughter’s death: mom

[Edmonton Sun 10/21/12 by Dave Lazzarino]

Delonna Sullivan’s case can be read in our How Could You? post here

Read More about Samantha’s Law passed in her name here

REFORM Puzzle Piece

Update:Hat tip to a reader who forwarded on this death inquiry and explanation.

A pdf of the 2011 inquiry can be read in total on the Alberta Justice website here. We will share excerpts below.

Samantha Lauren Martin  of Morinville, Alberta was 13 when she died on December 3, 2006.  She had a condition called  Tetrasomy 18p. .The report says that she was placed into foster care voluntarily at 1 month of age because the biological parents were overwhelmed with the care. She died without having a cause established after she was returned to her biological parents.

In the custody of her foster parents, she was very underweight and suffered fractures. Visits by CPS workers were woefully inadequate and the training of these workers was also inadequate.  Furthermore, the report details bring up the question of whether she had an undiagnosed seizure disorder as well, pointing to medical neglect while in state care that may have led to her death. The conclusions reached by this inquiry are pathetic.

A key section to her background that our reader points out is in the following paragraph of the report:

 

“She was placed with the Himschoot family near Morinvilleon August 3, 1993. A Permanent Guardianship Agreement was signedon October 24, 2001. Samantha’s biological parents were in telephone contact with the Himschoots, and reinitiated contact with their daughter, commencing when she was approximately 3 years old. Their contact with Samantha increased over time, and eventually led to joint guardianship of Samantha on October 24, 2001. In April 2006 Samantha increasingly spent time with the Martins, and eventually Samantha returned to live with her biological parents, not long before her death at the age of 13. Samantha appeared to be thriving after returning to her parents full time on June 27, 2006. Samantha gained weight, going from 49 pounds at the time of her return, which was her approximate weight for the previous 3 years, to 60 pounds by the end of July 2006, and looking much healthier in photos taken after her return to her biological parents. Samantha was nonverbal, but after her return home had started to acquire a few more words. In October 2006, Samantha was seen by Drs. Watt and McIvor at the Glenrose Rehabilitation Hospital Physical Medicine Clinic and it was noted that she had gained 6 kg in weight and 2 cm in height since her examination one year earlier.”

Our reader shares the following: “This statement is an inaccurate reflection of fact:

“Samantha’s parents decided to place her in foster care, for a number of reasons, including their grief at learning of the diagnosis, an unfortunately pessimistic prognosis and an unfortunate impression formed by Mrs. Martin that foster care would offer Samantha greater special services than would be affordable for her if she remained with her biological parents.”

In actuality, directly following prognosis, 2 social-workers arrived at the Martin home and indicated that anticipated medical care and therapies would not be offered to Samantha unless guardianship was taken over by the government. Family asked whether they could surrender guardianship and have Samantha remain at home or if Samantha could reside elsewhere, but maintain custody and both scenarios were denied. The family was told that the only option available if they “want to offer her a chance at life” was through out of home placement and that this route was “the kindest thing” they could do for their daughter.

*”A Permanent Guardianship Agreement was signed.”  Note:  This contract was an Agreement and NOT an Order because no issues of maltreatment or negligence ever existed with natural family home. *The Martin family was also told by the social-worker and foster mother that the foster parents were also guardians; that a “3-way guardianship split” existed between the Ministry, foster parent and natural parents. In reality, only the natural parents had attained guardianship status, yet the truth of their formal legal rights was denied and only revealed as Samantha spent the last days of her life in the hospital dying.”

The report explains the immediate circumstances before Samantha’s death:

“Tragically, Samantha became ill on November 29, 2006. She came home from school retching, and began vomiting. She later experienced diarrhea as noted by Mrs. Martin. Samantha settled in the evening and was left with her older brother while the Martins went to the bank, but unfortunately, Samantha’s condition worsened. Her brother phoned his parents to say Samantha had stopped talking. The Martins returned home, called an ambulance and Samantha was taken to the Sturgeon General Hospital in St. Albert. She was subsequently transferred to the University of Alberta Stollery Children’s Hospital, where a decision was ultimately made to remove life support. She passed away on December 3, 2006. The fact that Samantha was on life support for a period of time contributed to the difficulty in assigning a cause to Samantha’s death. It is known that her heart stopped; much less clear is why it stopped. ”

Excerpts of Samantha’s medical history that our reader has highlighted as are follows (Rally has further highlighted red flags in red text):

“The Court heard from Dr. Cody and Dr. Hale, a geneticist and pediatrician respectively, who are leading experts from the University of Texas at San Antonio with respect to this rare genetic condition. They have very extensive knowledge and experience with Tetrasomy 18p. They testified that to the best of their knowledge, it does not appear that Tetrasomy 18p is associated with any indications of reduced life expectancy.”

“Based on this analysis, it appears that 21 per cent of the children with Tetrasomy 18p have seizures. Many have gastrointestinal difficulties, but other than feeding difficulties especially in the early years of life, the children with Tetrasomy 18p were not noted to be particularly thin or frail. Dr. Maryanne Thomas, a geneticist at the Alberta Children’s Hospital, also gave evidence in the inquiry that in her opinion there is no evidence of any link between Samantha’s Tetrasomy 18p and her death. ”

“Children’s Services does not appear to have sought an expert opinion on the total number of fractures and the plausibility of the various explanations offered for them, or on the plausibility of explanations offered for various bruises which caused school staff working with Samantha to raise concerns with Children’s Services. Samantha herself was nonverbal, and could not be interviewed about these matters. However, although Samantha had a number of bruises on her face and neck and also suffered a number of fractures of her bones while in foster care, including fractures on two separate occasions of her thigh bone.”

“Natasha Dancause [Kowalsky] became involved in Samantha’s case in January and February of 2006. Ms. Dancause was a specialized investigator with Children’s Services”

“Reports were received from several school staff members of scratches and bruises on Samantha’s head and neck that were increasing in frequency since Christmas 2005, and concerns about the contents of Samantha’s lunch compared to the larger more balanced lunches provided to the biological son of the foster parents. School staff reported to Children’s Services that when this was raised with the foster mother, the response was to tell the school to fill Samantha up with water. There was particular concern because Samantha only weighed approximately 51 pounds at 12 years of age and had gained only 2 pounds in 2 years”

“Ms. Dancause did not meet with Samantha and did not make any calls to any doctors responsible for Samantha’s care. She relied on case workers and support workers to share information. ”

“Ms. Dancause decided on February 21, 2006 that the complaints raised about Samantha’s care did not require an investigation. The lack of records of medical checkups noted in a Children’s Services file review from December 2005 seems not to have been on the radar. Dr. McGonigle is the pediatrician who saw Samantha from time to time when her foster parents brought her in. He noted it was not a very thick file for someone with Samantha’s condition. He usually sees kids like that once every 3 months, and at least once a year for a complete checkup. In contrast, he saw Samantha for the first time in 2000, with a complete checkup in 2002, one when she was 8, and in June 2004. When she became his patient he was not able to obtain the file from the previous doctor who had cared for her. ”

“At age 11 Samantha was below the 5th percentile for weight and gained fairly little after that. Dr. McGonigle testified that low weight would be the result of low caloric intake. It does not appear from the evidence that the low weight was the result of Samantha’s Tetrasomy 18p, and it appears that Children’s Services staff may have erroneously attributed her low weight to her genetic condition. ”

“Samantha was returned to her biological mother and gained a healthy amount of weight,”

“The autopsy report indicates that Samantha weighed 42 kg and was 1.42 m tall at the time of her death.”

“Samantha weighed far less than she should have for a considerable length of time”

“Lorna Huff testified at the Inquiry. She was the assigned caseworker for Samantha Martin from September 1998 to August 2005. She does not have a degree in social work, which is not required in the province of Alberta.”

“Her responsibilities included seeing the child, having contact with the foster home, to be aware of everything that was going on in terms of the care Samantha was receiving, to talk to the doctors, to the foster mother, and to see the child in face to face visits, as well as having contact with the biological mother, to ensure the child’s best interests were met. A case conference was held at Samantha’s school November 21, 2002, where concerns were raised by the school that there was a possibility Samantha might be suffering from seizures, and suggesting that the doctor be consulted with respect to an encephalogram to rule out a seizure disorder. A report was prepared setting out in detail the substance of the meeting and the recommendations (Exhibit 6). Mrs. Huff’s notes from the case conference indicate “E.E.G. to rule out seizure disorder” and the note had a star beside it to indicate to Mrs. Huff that it was important to follow up on.”

“Mrs. Huff felt the foster mother was aware of the seizure issue,”

“Dr. McGonigle was not advised of seizure activity by Mrs. Himschoot, and never received a copy of the consultation report which referred to the need to assess for possible seizures. Dr. McGonigle testified that if he had seen the report he would have assessed Samantha for seizures. ”

“Five days after the November 21 case conference, there was a further meeting (this time an Individual Program Plan meeting to discuss Samantha’s educational goals) at Samantha’s school where many of the same individuals were present, as well as the foster mother and the caseworker. Although the records do not indicate that the issue of possible seizures was addressed at this meeting, it does appear that the foster mother indicated that she planned to take Samantha to Dr. McGonigle for a medication review.”

“contact notes from the Children’s Services file together with Dr. McGonigle’s records and evidence appear to suggest the issue discussed was Resperidal which was being prescribed for behavioral issues and which had nothing to do with seizures.

Mrs. Huff believed that Mrs. Himschoot had a lot of experience with medically fragile children, as a large number of such children were placed in her care, and Mrs. Huff appears to have been under the impression that Samantha had monthly visits with doctors. However, this does not appear to be an accurate understanding, as an EEG was never sought by the foster mother for Samantha, and although the foster mother did take Samantha to the doctor from time to time for various needs, she did not bring her for regular physical checkups with the pediatrician. The health records disclose a period of 3 years where Samantha was not seen by a pediatrician or family doctor.”

“This was unusual for a child with her complex medical needs, according to Dr. McGonigle and Dr. DeCaen. Mrs. Huff, although she was the caseworker for Samantha, appears to have been ill informed as to the frequency or nature of Samantha’s medical visits, and relied heavily on what the foster mother told her was going on. Mrs. Huff did not notify Dr. McGonigle, the pediatrician, about the suggestion that an encephalogram be done to rule out a possible seizure disorder. She assumed the foster mother…had done it. Mrs. Huff never attempted to confirm with Dr. McGonigle or Mrs. Himschoot that the seizure issue had been assessed by the doctor. Mrs. Himschoot testified she did not convey a concern about seizures to Dr. McGonigle, as she felt she would want to know more before going to a doctor, and testified that she feels the same way now. Mrs. Huff testified that she spent time with Samantha and never saw any seizure activity. Exhibit 6, a Consulting Services report which discussed the school’s concerns about possible seizures, was shown to Mrs. Huff, who indicated she had received it but did not forward the document to Dr. McGonigle; she did not know if the report was sent to the foster mother or biological mother. The consultation report recommended that the report be forwarded to Dr. McGonigle.”

“The school felt that it required written permission from the foster mother prior to forwarding the report to Dr. McGonigle. Mrs. Huff felt “it did not seem to be a big issue”.

Mrs. Huff was required to have in person visits with Samantha at least once every 3 months, but longer periods went by; 14 months went by with no face to face visits according to Children’s Services’ internal review,”

“There were also gaps of 7 or 8 months at times,”

“(A previous worker for Samantha also had had only 3 face to face visits with Samantha during the 26 month period”

“(according to the Children’s’ Services file review), whereas policy would have required at least 8 or 9 visits in that kind of time frame Lorna Huff testified that Samantha’s condition came with difficult behavioral issues and Mrs. Huff felt she would never have been able to find a placement for Samantha that would have been equal to let alone better than the quality of care she was receiving in the foster home.

Valerie Jensen took over from Lorna Huff in 2005 as the Children’s Services case worker for Samantha. On September 15, 2005, a Children’s Services review of the file found no record of annual medical or dental checkups. A further December 2, 2005 review of the file was completed by Diane Martin who noted that there had been no face to face meetings with Samantha since February, and also again noted that there was no indication of annual medical/dental checkups in the file.

It appears there were no face to face visits documented with Samantha after February 2005 until November 23, 2005, and then again until March 21, 2006”

“Upon her return to the biological parents, the Martins, Samantha was taken to the pediatrician Dr. Roseman, who on November 15, 2006 arranged for an EEG to investigate the issue of seizures, after the biological mother and a teacher of Samantha’s had witnessed what they felt might be seizures; this EEG was to have taken place on November 30, 2006….Mrs. Martin testified that Dr. Roseman witnessed a seizure in the office on November 14, …(Mrs. Martin also told Children’s Services in September 2006 that she had told the foster mother in 2002 about her concern about seizures in children with Testrasomy 18P but nothing was done;”

“On Samantha’s November 15, 2006 examination by the pediatrician, Dr. Roseman, Samantha appeared to be doing well and weighed 61 pounds, but Samantha passed away before Dr. Roseman had a chance to complete the investigation into whether she required treatment for seizures.

The issue of possible absence seizures had been raised long before, by the Physical Medicine Clinic at the Glenrose Rehabilitation Hospital, on June 4, 1996, when Samantha was 3 years old…it was noted that the foster mother was advised to discuss the issue of the possible absence seizures with Dr. Berhmann, who was at that time Samantha’s pediatrician,…Dr. Berhmann’s file was not available to the inquiry, as it was picked up by Mr. Himschoot in 1997 and apparently misplaced or lost…It appears however from Mrs. Himschoot’s evidence that the seizure concern likely was not followed up on.”

“Dr. Dowling’s training and extensive expertise is specifically with respect to the issue of cause of death…. I prefer the evidence of Dr. Dowling. Dr. Dowling testified as an expert in forensic pathology. For 18 years he was the Chief Medical Examiner for the province of Alberta. He has a wealth of experience in identifying cause of death…Dr. Dowling did testify that some of the more plausible causes that may have led to Samantha’s death are a seizure.”

“He testified that there are really only a couple of things that come to mind as possibilities. From Samantha’s history of absence seizures, he noted that people with seizure disorders can die suddenly and unexpectedly from having a seizure even though it is no different than other seizures they have had previously. It is not known why this happens, but it does occur. He testified it is difficult to say whether Samantha had a seizure, but that it is certainly possible, in which case the cause of death would be seizure disorder due to her underlying Tetrasomy 18p. He testified that this is possible even in the case of absence seizures.”

“Dr. Dowling testified that untreated seizures can certainly put a person at greater risk of dying because of their seizure disorder. However, a seizure disorder can result in death even where the individual is being treated and taking appropriate medication. He agreed it was fair to say there would be an increased risk without medication, but stated that it would not be absolute. Dr. Dowling’s evidence about the possibility of seizure disorder playing a role in the cause of death was persuasive in light of his experience and expertise.

Recommendations for the Prevention of Similar deaths:

I find that the manner of death was natural, and that the cause of death may well have been a seizure, but due to the absence of evidence, it is not possible to say that this was the probable cause of death. However, given the evidence that seizures were likely an issue for Samantha, and in light of the extensive evidence I have heard, I am of the view that it would be appropriate in this case, to make certain recommendations to aid in the prevention of other deaths bearing in mind the purpose of the legislative provisions for the Fatality Inquiries Act clearly includes the attempt to avoid preventable deaths in the future.

The evidence in this case leads me to make the following recommendations: That Children’s Services should ensure that those caseworkers who work with a foster child have accurate and up to date information from a reliable medical source about the child’s disability and in particular, the impact, if any, of the disability on the health, weight, and fragility of the child. This needs to be well understood in order for the worker to make informed assessments about how the child is doing in care, especially in the case of a nonverbal child who cannot communicate concerns with the child’s worker.

That Children’s Services should look at enhancing current policies to ensure that children are actually receiving their annual medical checkups as required, including a diary system so that the issue is flagged and not inadvertently overlooked.

That where a recommendation comes from a reliable source (such as a school assessment) that a doctor examine the child for a possible medical issue that the child may be experiencing, that processes are in place to ensure the issue is flagged for follow up by Children’s Services in an effective and meaningful way, including required entry by the Children’s Services child care worker or other support staff at Children’s Services into a diary system.”

Our reader explains the following: “*Recommendations are disappointing because all these convey is that workers involved should have been doing their job; recommending workers perform their job is futile in the absence of repercussions for failing duty. Furthermore, although the needs of children who are non-verbal are more difficult to access, it is not impossible to do so if provided proper outlet. Therefore, assigning workers who are specifically trained to communicate with individuals with special needs is crucial. ”

Ensure that caseworkers for the child have a reasonable case load so that they have the time they need to be able to adequately document and follow-up on medical needs of the child.”

Additional REFORM Puzzle Piece

As our reader states, what is really needed are trained caseworkers, access to comprehensive medical care and a mechanism to track when children are not being followed adequately by caseworkers and punishment/correction when that is discovered.

Update 2: “Samantha Martin was born with a rare chromosome disorder. Her parents didn’t have the money to pay for the care she required on their own. They took the advice of Alberta Childrens’ Services and placed her in foster care. It was a way to get Samantha access to better care. But the Martin’s were only able to get occasional visits with Samantha and she went years without seeing a doctor. A far cry from the care they were promised.