4 girls, 4 suicides, and a desperately broken system

Jorge Barrera
APTN National News
Girl 1: There was no crib in the home when she was born and by 16 she was dead by suicide.

Girl 2: Night after night she heard the beatings through the wall of her bedroom and by 15 she was dead by suicide.

Girl 3: She was raped at 14 and by 15 she was dead by suicide.

Girl 4: She saw her father sexually assault a relative and by 12 she was dead by suicide.

The stories of these four girls, whose identities cannot be revealed to protect the privacy of their families, are detailed in a leaked 2014 Manitoba Children’s Advocate Special Investigation Aggregate Report into the deaths of 14 children aged two months to 17 years.

Their stories reveal the overwhelming pressures and pain faced by children living in poverty-afflicted First Nation communities with deep historical traumas, that are serviced by threadbare social welfare agencies, and where perpetrators—wounded by their own histories of abuse—slide repeatedly through cracks in the justice system.

The 14 children died between 2009 and 2013 and their families come from the Island Lake First Nation communities of Garden Hill, Red Sucker Lake, St. Theresa Point and Wasagamack. The four communities sit about 400 kilometres northeast of Winnipeg. They are accessible only by water or air. During the freeze-up and thaw transitions between seasons, air access is their only link to the rest of the province. Some homes here do not have running water and sometimes two to four families share one house.

The legacy of Indian residential schools still casts a long shadow over all four communities.

“Band-Aids will not fix a broken limb …” 

The four communities have an on-reserve population of about 10,000 people, with roughly 1,000 band members living off-reserve.

The families of all 14 children passed through the files of the Island Lake First Nations Family Services (ILFNFS) agency which, according to internal provincial and federal reports obtained by APTN, faced serious shortcomings in delivery of services. None of the 14 children were in care at the time of their deaths.

In 2011, ILFNFS recorded having 370 children in care.

Eleven of the children died in their home communities and three died in Winnipeg, including two of the girls who died by suicide. According to the report, three infants died of natural causes, two infants died from sudden and unexpected infant death, two children died from drowning, one died in a house fire, one died in a snowmobile accident and another as a result of alcohol-related hypothermia.

The 14 deaths echo those of other children recorded with heart-breaking consistency across the country in First Nations facing the same grinding poverty as the Island Lake communities of northern Manitoba.

Darlene MacDonald, Manitoba’s Children’s Advocate, released a statement Monday condemning the leaking of the special investigation document, which was first reported on by the Winnipeg Free Press.

“I am shocked and saddened that a confidential child death review completed by my office in 2014 has been unlawfully given to the media,” said the statement. “Child death reviews completed by my office involve broad and intensive examinations of some of the most difficult circumstances Manitoba families can face.”

MacDonald’s statement said it’s unfair to place blame for the tragedies solely on child welfare agencies because they are often the only tattered safety net in a realm of multi-layered dysfunction caused by government-sponsored poverty.

“With no comprehensive investments in rural communities by our provincial and federal governments, challenging situations can quickly become crisis situations, and then a child welfare agency can be left to scrabble together what meager supports they can from a scant list of accessible options in a community,” said MacDonald’s statement. “Band-Aids will not fix a broken limb, and patchwork funding will not bring about the equity of services that is needed beyond city limits. Until real investments happen, child welfare agencies will continue to sometimes be the only organization in a community that can piece together minimal supports.”

Children placed into foster homes deemed “high risk”

APTN is also in possession of the child death review and has decided to report on aspects of its contents precisely because it reveals a broken system that is failing First Nation children. It also offers some potential clues behind the suicide epidemic gripping Indigenous communities across the country.

APTN has also obtained separate internal federal and provincial documents that reveal both Winnipeg and Ottawa were aware of deep failures in the operations of the ILFNFS for years, including the placing of children in the care of foster parents deemed “high risk” by the provincial child abuse registry.

The ILFNFS agency was recently thrown into turmoil after the chiefs of the four Island Lake First Nations—under the auspices of the Island Lake Tribal Council—ordered the ILFNFS board to suspend the executive director, Brenda Wood, who took the position in 2015 and began implementing reforms that led to the termination of several staff members.

Some of the terminated staff pressured the chiefs into moving against Wood who was well-liked by the board, according to sources.

The First Nations of Northern Manitoba Child and Family Services Authority—known as the Northern Authority—announced last week it entered into a co-management agreement with ILFNFS. The Northern Authority oversees First Nations child welfare agencies in northern Manitoba.

The board is expected to submit a report on Wood’s performance to the chiefs sometime this week.

On Monday, Indigenous Affairs Minister Carolyn Bennett announced $550,000 to Manitoba First Nations, distributed through the Assembly of Manitoba Chiefs, for ongoing consultation on Ottawa’s planned reforms for on-reserve child welfare.

In a ruling delivered last year, the Canadian Human Rights Tribunal found Ottawa discriminated against First Nations children by underfunding on-reserve child welfare services. Ottawa is currently fighting non-compliance motions filed by Cindy Blackstock, head of the First Nations Child and Family Caring Society, the Assembly of First Nations, the Chiefs of Ontario and the Nishnawbe Aski Nation for failing to follow through with changes ordered by the ruling. In a submission to the Tribunal, Canada said it believed it was in compliance with the tribunals orders.

If you’re experiencing emotional distress and want to talk, call the First Nations and Inuit Hope for Wellness Help Line at 1-855-242-3310. It’s toll-free and open 24 hours a day, 7 days a week.

The ILFSFS agency is primarily funded by Indigenous and Northern Affairs with contributions from the province for the care of children living off-reserve. It was created in 1997 under a tripartite agreement first signed in 1983 by Manitoba Keewatinowi Okimakanak (MKO), the federal and provincial governments. MKO represents 27 northern Manitoba First Nation communities.

Provincial and federal reviews have revealed several major deficiencies in the operations of ILFNFS, according to internal documents obtained by APTN.

One review in 2012 found that almost all of the agency’s case management files failed to meet provincial standards including: Up-to-date photos of children in care were missing in the majority of files; the agency failed to have face-to-face contact with children in care every 30 days; the agency failed to move quickly on abuse investigations.

According to one example cited by the review, a particular abuse investigation did not begin until months after the information reached the Northern Authority, which oversees the agency. A further investigation revealed that the Island Lake agency received information about the abuse months before it was transmitted to the Northern Authority, leaving children facing the risk of more abuse during the time span of inaction.

The 2012 provincial review along with a 2013 federal audit found alarming lapses in the placing of children into foster homes deemed “high risk.” The reviews found that one child was placed in a foster home with a convicted child abuser and another in a home with an individual facing child abuse charges.

“The review team was informed that a number of children were placed in homes that could have posed a safety risk due to the following reasons: there were foster parents where the Child Abuse Registry checks were coming back with a ‘high risk’ rating; unlicensed foster parents; recommended home improvements that were not made; and a child remaining in a Place of Safety beyond the maximum limit of days,” said an audit report submitted to Indigenous and Northern Affairs in June 2013.

The Children’s Advocate’s investigation report found similar problems with the agency after reviewing the 14 deaths for the 2014 report.

“Minimal documentation was found in all but two of the files examined. In one case confirmed as open with ILFNFS, no file could be found. Case management issues were found in relation to services to 12 of the 14 families and included: gaps in service, no assessment, and a lack of effective follow up regarding child protection concerns,” said the Children’s Advocate’s report. “Eight of the files examined contained no case plans. Five case files had been closed before child protection concerns were adequately addressed, and one file remained open long after service to the family had ceased.”

4 girls, 4 suicides … 

Examples were found in the files of each of the four girls.

Girl 1 lived in a home with no water or sewer service, the only heat in the cold months came from the wood stove. Her family’s case file indicates agency involvement at various points over a decade but little connecting information.

Then, there was a report Girl 1’s relative had been raped. The nurse told the RCMP. There was a plan to send the relative, who was 13 at the time, on an immediate medevac to Winnipeg for a forensic examination. The plan was changed because the attack happened a week earlier. The relative was finally taken to Winnipeg five days later. She was interviewed by an agency abuse investigator in Winnipeg and the RCMP took over, eventually charging a suspect.

Girl 1’s relative did not received any counselling. The RCMP informed the agency it charged an alleged offender. After that, the agency did not have contact with the family until Girl 1 died by suicide. She was 16.

“No information regarding service provided to the family following (Girl 1’s) death could be found on file,” said the Children’s Advocate’s report.

Girl 2 wanted her mother to leave her abusive father who would wait until the children were asleep before beginning the beatings. He sometimes beat Girl 2’s mother all night. There was drinking, this brought in the ILFNFS. The social workers would never meet with the mother alone with the children. They would always meet with him there and he would blame the mother for everything. Before these planned meetings with the social workers the father threatened the mother with more pain if she revealed anything about the abuse.

Then, Girl 2 started calling the RCMP on her father. They would arrive, take him into custody for the night and release him the next morning. If he was charged, the case would be remanded so many times Girl 2 would stop showing up to give testimony against him. The father would return home and threaten Girl 2.

The mother tried to seek help from ILFNFS when Girl 2 started talking about suicide, but little was done.

Then, Girl 2 died from suicide. She was 15. It was a closed casket.

The Children’s Advocate’s report said the agency provided no support to the family after the suicide.

Girl 3 was raped at 14 and Winnipeg police charged a suspect. Child and Family Service’s own abuse investigator determined the matter “inconclusive” after failing to interview the alleged perpetrator. A month later, Girl 3 attempted suicide and was hospitalized. She was in the care of ILFNFS’ Winnipeg office. She was released from hospital a couple of weeks later with a prescription for Seroquel, an antipsychotic drug primarily used to treat bipolar disorder and schizophrenia.

Then, during a winter month, Girl 3 died by suicide. She was 15. A review of the case determined ILFNFS’s Winnipeg office did not meet the standard for monthly contacts with the family because of a high caseload. ILFNFS was also not provided details of Girl 3’s rape until after her death. The review determined the abuse investigator’s finding of “inconclusive” may “have added to (Girl 3)’s stress.”

That summer, charges were stayed against the male charged with raping Girl 3.

By the time the ILFNFS Winnipeg office took over Girl 4’s family’s file, Child and Family Services’ (CFS) abuse investigators had hit a dead-end probing sexual abuse allegations involving two relatives against Girl 4’s father. When the file was transferred by CFS to ILFNFS it remained untouched for four months. Then, there were some notes and a case plan included in the file.

Two years after the transfer, ILFNFS received a phone call that Girl 4 witnessed her father sexually assault a relative. A social worker visited the home the next day and noticed scars on Girl 4’s wrists. The worker told Girl 4 if she had suicidal thoughts she should talk to her mother or a teacher.

A CFS abuse investigator received the file five days following the phone call. The Winnipeg police was not notified. The abuse investigator continued the probe for five months. Girl 4 died by suicide. The CFS abuse investigation ended.

It was: “inconclusive.”

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Jorge Barrera

[email protected]