Gove Inquiry into Child Protection
The Honourable Judge Thomas J. Gove, Commissioner
Leonard T. Doust QC
Robert W. Cooper
Keith R. Hamilton
280 - 666 Burrard Street,
Vancouver, BC V6C 2X8
Telephone (604) 775-1966
Facsimile (604) 775-1968
An Independent Commission of Inquiry appointed by the Province of British Columbia
The Honourable Ujjal Dosanjh
Province of British Columbia
Victoria, British Columbia
Dear Mr. Dosanjh:
I am pleased to enclose my report to you, for delivery to the Lieutenant Governor in Council and to the citizens of the Province of British Columbia.
I can think of no work more important than that in which I have been engaged for almost 18 months examining the way we protect our children. I was privileged to have the opportunity to carry out this review.
There is a consensus of opinion in our province about the need to protect children, which crosses all economic, geographic, ethnic and political boundaries. Everywhere I went I was told that child protection is too important an issue to be treated as a political pawn. In public meetings and private discussions throughout British Columbia there was universal acceptance that the welfare of children is everyone's concern. The way in which the media reported on the Inquiry's work indicated an attempt to educate all British Columbians about this important issue.
This report summarizes what I have learned and, where appropriate, sets out my recommendations for change. My letter of transmittal is woven throughout the report. It serves to introduce new issues, and also allows me to step back from the formal discussion and provide some personal observations and impressions.
I begin by setting out some of the background that led to this Inquiry.
On October 3, 1986, Matthew John Vaudreuil was born in the northern British Columbia community of Fort St. John. Five and a half years later, on July 9, 1992, he died in Vancouver. Throughout his life he was a client of the Ministry of Social Services. The public learned some of the details of his life and death in the Spring of 1994, after his mother pled guilty to his manslaughter. Many people were outraged some called for accountability and others demanded the resignations of public officials who were involved.
On May 17, 1994, the Honourable Joy MacPhail, Minister of Social Services, addressed the Legislative Assembly. She filed a copy of the Superintendent of Family and Child Service's report into Matthew's life and death. The report said that Matthew suffered from neglect and abuse throughout his short life, and that services and programs intended to protect him failed to do so. The report concluded that Matthew should have been removed from his family home.
At the same time, the minister introduced two new statutes that she said would help to address the problems identified in the Superintendent's Review: the Child, Family and Community Service Act and the Child, Youth and Family Advocacy Act. Finally, the minister announced this independent commission of inquiry.
Two days later the Cabinet, on behalf of the Government of the Province of British Columbia, appointed me to inquire into, report and make recommendations on the adequacy of services and the policies and practices of the Ministry of Social Services in the area of child protection, as they related to Matthew.
I decided to divide the inquiry process into two parts. During Part 1, I would hear evidence from those who had been involved with Matthew and his family, those who took part in the Superintendent's Review and those who were the ministry's senior managers responsible for child protection policy and management of child protection services. During Part 2, I would hear from the public and I would meet with many people, including youth who are or who had grown up in the care of the ministry, social workers, senior government officials, labour leaders, associations of foster parents, community organizations and groups representing parents and grandparents. I would seek solutions to the systemic problems that marked Matthew's tragic life and led to his death.
On being appointed, I retained commission counsel to provide legal advice and to present the evidence at the Inquiry's hearings. I hired administrative and research staff and began to examine the facts. Two Inquiry researchers travelled to Fort St. John, Vernon and Vancouver, where Matthew had lived, to interview people who had known Matthew and his family and who might be potential witnesses. Another researcher read all the ministry files regarding Matthew and his family, and advised me on the practices and procedures followed by ministry social workers who were responsible for these files.
At the outset, none of us had any idea of the amount of time and energy the Inquiry would demand. My staff and I examined files, interviewed people who had known Matthew and his mother, and heard stories of neglect and abuse from hundreds of other people. I knew that I would want to be able to compare what happened to Matthew to the lives and deaths of other children known to the ministry.
I also knew that I needed to hear from people in the community about problems with British Columbia's child protection system. To that end, I invited written briefs or letters from interested individuals and organizations.
I learned a great deal, from children and youth, about what it means to live in an abusive or neglectful home, or to be removed from one's parents to grow up in foster care. The Federation of BC Youth in Care Networks, an association of community youth groups from throughout the province, helped me greatly. I hired a member of the Federation to work on my staff and she proved to be most important in providing real-life input. (Throughout the report, when I use the terms "child" or "children," I am including "youth.")
Aboriginal organizations helped me to understand why such a disproportionate number of aboriginal children are in ministry care. I am indebted to a First Nations woman, one of my researchers, for helping me to appreciate the unique nature of aboriginal child welfare, and for arranging meetings and public hearings with aboriginal peoples.
Throughout this report there are references to aboriginal child welfare, and two of the research papers specifically explore related issues. However, the report does not attempt to examine how aboriginal communities ought to practice child welfare, as I recognize that many aboriginal peoples either are, or are in the process of becoming, responsible for child protection and child welfare generally within their communities. As I say later in the report, the larger community has much to learn from the traditional ways in which the first peoples of this province cared for their children before the Europeans arrived.
I was also assisted by the previous work done by others who had examined related child protection issues. For example, two community panels travelled throughout British Columbia in 1992 and heard oral submissions and received written briefs, and produced two reports: Making Changes: A Place to Start and Liberating Our Children -- Liberating Our Nations. I studied these reports and reviewed many of the submissions made to the two panels. I benefitted from their wide public consultation, without duplicating their work.
As the Inquiry's preparatory work progressed, it became clear that the information I would learn from examining Matthew's life and death, and from hearing and reading public submissions, would need to be supplemented by empirical and academic research on a wide range of child protection issues. Consequently, I commissioned a number of research projects. Each of the projects produced one or more research papers, which were influential in preparing many sections of this report. These research and background papers are listed in Volume Two: Sources. Copies can be purchased from the Queen's Printer.
The Inquiry's Part 1 hearings into Matthew's life and death started in Fort St. John on August 31, 1994. I decided to hold formal public hearings: witnesses would be examined under oath and ministry files and records would be open to public scrutiny. In my view, it was vitally important that the public have confidence in our child protection system. Matthew's suffering and death had thrown that confidence into question, and only an open inquiry process could restore it.
A number of television and radio stations applied for permission to record and broadcast the public hearings. As there was no opposition to the application, and because I wanted the hearings to be as open to the public as possible, I allowed for coverage of them by television and radio. Child protection has, for as long as anyone can remember, been conducted in secrecy, with at least the perception that social workers are not accountable. This secrecy does not serve the child that it is supposed to help nor any family that is under scrutiny.
I heard three weeks of sworn evidence in Fort St. John. The Inquiry then moved to Vernon for one week, and finally to Vancouver for five weeks. I heard evidence from 113 witnesses: Matthew's parents and relatives, ministry social workers, child care workers, home support workers, physicians and other members of the community who had been involved with him. The transcript of evidence covers more than 6,000 pages, and there is an equal number of pages of documents, mostly ministry and hospital records.
It was clear to me from the outset that the focus of the work of the Inquiry should remain on Matthew. It seemed wrong that we would refer to what happened to this little boy as a "case" or a "file." If Matthew's life was going to be publicly examined, I owed the respect to his memory to tell his life and death as his own story. My findings of fact and conclusions based on Matthew's life and death are called Matthew's Story.
My report is divided into two volumes. Volume One is Matthew's Story. It starts with a description of how children in British Columbia are supposed to be protected from abuse and neglect. To understand the facts of the story, the reader must know that the Superintendent of Family and Child Service and the Ministry of Social Services have the legal responsibility to ensure the safety and well-being of children.
I then tell Matthew's story, beginning with a description of the family into which he was born. I have included only those facts necessary to tell Matthew's story. Where there is a conflict between witnesses as to what happened, which arose infrequently, I have weighed the evidence and set out the facts as I conclude them to be. I have also named all the people who testified, including some of the professionals who were referred to in the ministry's files.
I raise two cautions. First, I tell the story of Matthew's life from his perspective, as though the services provided to him and his family were for him -- in other words, were child-centred. Regrettably, this was seldom the case. If Matthew's story was told as the evidence unfolded, there would be long passages in which he would not be mentioned at all. Although the ministry's legal and financial authority was to provide services to protect Matthew, services were in fact directed more to the benefit of his mother. The ministry, its employees and contractors lost sight of why a child protection service exists, and who they were supposed to be protecting.
My second caution is that Matthew's Story is very sad and will upset many readers, as it upsets me.