Executive Summary

Report of the Gove Inquiry into Child Protection in British Columbia



Matthew's Early Life in Fort St. John

Matthew was born to a mother who had been taken into the ministry's care when she was eight years old. Verna Vaudreuil had been severly emotionally rejected, neglected and physically and sexually abused. She went through numerous foster home placements while in the ministry's care and, by the time she turned 19, the ministry knew that she was incapable of financial self-sufficiency and of living independently.

Vaudreuil was 20 years old when she gave birth to Matthew in Fort St. John. The ministry was involved in his life from the outset; Vaudreuil received income assistance, and ministry staff approved various home support, child care and life skills worker services for him and his mother.

The home support worker and infant development consultant who worked with Matthew and his mother during his first year became concerned about the risks to Matthew posed by his dirty home environment and Vaudreuil's limited parenting skills. Matthew also began demonstrating self-abusive behaviour such as head banging and biting himself.

By the time Matthew was two, the ministry had received several reports that he was being neglected and physically abused, was often filthy and was living in appalling conditions. Matthew and his mother lived in a women's transition home for six weeks after she reported that she and Matthew had been physically abused.

Vaudreuil sought advice from ministry social workers about Matthew's temper tantrums and self-abusive behaviour. She also took Matthew to the hospital emergency ward numerous times for minor ailments, and several doctors noted her apparent difficulties in parenting Matthew.

Matthew's foster mother who babysat him when he was two and a half found that he acted violently toward both himself and another child in her home by scratching and biting. After three months, this behaviour led the foster mother to refuse to care for Matthew any longer. When Vaudreuil was later hospitalized for two weeks, a home support worker who lived with Matthew observed him to thrive: he put on weight, he laughed and his self-abusive behaviour stopped. When Vaudreuil returned, he deteriorated; he and the home grew dirtier and his tantrums and self-abusive returned. A psychologist who evaluated Matthew at the request of the Fort St. John Child Development Centre found that his severe language delay qualified him as a special needs child, and recommended that he attend the child development centre preschool.

Shortly before Matthew turned three, Vaudreuil and Matthew moved to Lumby, near Vernon, where she married. Ministry social workers in Fort St. John alterted social workers in Vernon to the need for the ministry to become involved with the family, noting that Vaudreuil was mentally handicapped and citing concern for her ability to parent Matthew. In spite of these warnings, the Vernon social workers made few efforts and never did locate Matthew and his mother in Lumby.

Matthew Moves to Vernon

Vaudreuil stopped living with her husband after two months. She claimed that he had abused Matthew. An RCMP officer took Vaudreuil and Matthew to a women's transition home, but concluded that Vaudreuil's allegations did not warrant futher investigation.

Transition home staff observed that Matthew screamed, bit himself, hit his head on the floor, and that Vaudreuil's seriously inadequate parenting skills aggravated Matthew's behaviour. They reported their concerns to a ministry social worker.

After two months Vaudreuil and Matthew moved to the transition home's independent living residence. Vaudreuil did not participate in any of the counselling programs, and people in the residence observed her apartment to be dirty and disgusting. Matthew's self-abuse continued.

When Vaudreuil told a ministry social worker that she could no longer care for Matthew, it was agreed that Matthew would be placed with a foster family for two weeks full-time, and then on an intermittent basis. Home support services were cancelled when Vaudreuil did not cooperate. A child care worker hired by the ministry had found Vaudreuil resistant to meeting with her until Vaudreuil's social worker threatened to cancel the foster parent's services unless Vaudreuil cooperated. The foster mother eventually cancelled the intermittent care agreement on her own initiative. Vaudreuil was leaving Matthew longer than agreed and, without speaking to the foster mother, Vaudreuil's social worker agreed with Vaudreuil that the foster mother would babysit Matthew on the days that she was not contracted to provide foster care.

Vaudreuil and Matthew moved in with a man she had met at a bar, but neighbours soon complained of screaming and of Vaudreuil's attempts to force them to babysit Matthew. The social worker took no significant steps to determine if it was an appropriate living arrangement for Matthew. The man eventually evicted Vaudreuil and Matthew. They moved back to the transition house and, shortly thereafter, to Fort St. John.

Matthew Returns to Fort St. John

Vaudreuil and Matthew moved back to Fort St. John in April 1990, when Matthew was three and one-half years old. Vaudreuil sought advice from her financial assistance worker about Matthew's tantrums and self-abuse. At the child development centre preschool he was assessed as interacting with other children at the level of an 18-month-old.

In December, Vaudreuil asked ministry social workers to put Matthew into a foster home while she took courses on parenting and anger. The social workers refused because they were not convinced of her commitment to making effective use of a break from parenting.

The ministry continued to receive reports that Matthew was dirty, neglected and abused, and that the home was filthy and smelled putrid. The psychologist who had previously evaluated Matthew for the child development centre did so a second time, and concluded that Matthew needed a full-scale behaviour management program at home, but that results were not likely to be achieved because of Vaudreuil's limited parenting abilities.

In March 1991, while Matthew and Vaudreuil were living with her father, a child care worker found Matthew's living environment to be so filthy that she returned with a social worker. The social worker returned several times, threatening to remove Matthew if the situation did not improve, and ultimately insisting that Vaudreuil find her own apartment. This did not occur until May 1991.

Over the next few months, Vaudreuil's aparment became a "flop house" for homeless and runaway youth. Vaudreuil reported to the police that her boyfriend had cut Matthew's penis with a knife, an accusation that the boyfriend denied and that was not substantiated. Matthew's uncle reported to the ministry that Vaudreuil was using drugs and was a prostitute, and that Matthew was not being fed. A social worker spoke with Vaudreuil, but did not visit the home or speak with the uncle, anyone else who knew the family or Matthew himself.

A week later a youth took Matthew to the hospital at 1 a.m., claiming that Matthew had choked and stopped breathing. The youth reported that Vaudreuil was drunk and had gone out, and the youth did not know how long Vaudreuil would be gone. The next night the ambulance service attended Vaudreuil's apartment and found the same youth lying on the floor, apparently unconscious, and another youth in a closet apparently on drugs. Matthew looked dirty, underweight and neglected.

During the summer there were more reports that Matthew was being physically abused and neglected, and that the apartment was filthy, with maggots on dirty laundry in the bathroom and mould growing on food in the fridge. Social workers visited the home and found it to be a mess. Child care and home support services were provided, but Vaudreuil routinely missed appointments or did not cooperate.

When Matthew was almost five, he was suspended from his daycare when workers felt they could not manage his difficult behaviour without the assistance of a one-to-one child care worker for him. He was subsequently terminated from the daycare centre altogether when his mother made a scene about his suspension.

Vaudreuil then placed Matthew into a family daycare. The daycare provider reported to the ministry that she could not continue to care for Matthew because he was acting out physically and sexually with other children in her home. Ministry social workers never investigated.

In the autumn, a social worker referred Matthew to the Ministry of Health's Mental Health Services program. A psychiatric social worker saw Matthew and his mother three times, and concluded that Vaudreuil's lack of parenting skills was the main problem. A three- to four-month treatment program was proposed but was never undertaken because Matthew and his mother missed the next two appointments.

In December Vaudreuil began living with 18-year-old Patrick Johnson. Around Christmas a ministry social worker investigated an allegation that Matthew had been physically abused by his mother. When the physician who examined Matthew could not find absolute evidence of abuse, the social worker left him in Vaudreuil's care.

In January 1992 Matthew came to preschool in soiled clothes, and he was observed hitting himself and other children. In February, after preschool staff felt compelled to bathe him themselves and sent his filthy clothes home for Vaudreuil to see, he stopped attending altogether.

In early March, after Johnson, Vaudreuil and Matthew moved to Vancouver, a ministry social worker closed the file, even though she recorded in the file that there were protection concerns and that Matthew might need to be apprehended. Prior to their move, Vaudreuil's Income Assistance file had been closed and both mother and son placed on Johnson's assistance file in order to give Johnson a greater sense of responsibility.

Matthew in Vancouver

On March 3, 1992, Johnson applied for income assistance for himself, Vaudreuil and Matthew. A week later a social worker filled in an Intake form based on her telephone conversation with the Fort St. John social worker who told her that there should be ministry follow-up with this family. When the file arrived from Fort St. John on March 16, the social worker realized there were serious child protection concerns.

The intake social worker who was responsible for the investigation made several attempts to contact Johnson, Vaudreuil and Matthew, but did not meet the family face-to-face until May 21, 10 weeks after the intake telephone call from the Fort St. John social worker was received. No Alerts had been placed on the ministry's computer system and the intake social worker never discovered that the ministry had placed Johnson and the Vaudreuils in a Vancouver Hotel.

The social worker's primary concern was arranging a special needs placement for Matthew with the school board. He did not examine or talk to Matthew privately, and did not perform a risk assessment.

According to Johnson, when Matthew told him on July 8, 1992, that a man had been in Johnson and Vaudreuil's bedroom, Johnson went for a walk, feeling lost and confused. When he returned, Matthew was on the sofa. When Johnson noticed that Matthew was not breathing, he asked Vaudreuil to phone 911. Matthew was pronounced dead just after midnight in the emergency ward of British Columbia's Children's Hospital.

When Matthew died he was five years and nine months old. Not including supervisors, 21 ministry social workers had been responsible for providing him with services. At least 60 reports about his safety and well-being had been made to the ministry. He had been taken to the ministry. He had been taken to the doctor 75 times and had been seen by 24 different physicians.

How Matthew Died

The autopsy showed that Matthew had died of asphyxia, a lack of oxygen. This cause of death was consistent with Vaudreuil's statements to police that she had put her hand over Matthew's mouth and nose to stop him from yelling.

Although he was nearly six years old at the time of his death, Matthew weighed only 36 pounds. His face, arms, legs and back were covered in bruises. There were what appeared to be rope burns on his shoulders and wrists, as if he had been bound. His buttocks were covered in bruises and welts. He had a fractured arm, 11 fractured ribs and what looked like the imprint of a foot on his back. Matthew had been tortured and deprived of food before he was killed.

Conclusions From Matthew's Story

The Inquiry found that serious inadequacies in the ministry's child protection system, and in the provision of child protection services by ministry social workers, contributed to Matthew's suffering and death:

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