Executive Summary

Report of the Gove Inquiry into Child Protection in British Columbia

Volume One: MATTHEW'S STORY


LETTER OF TRANSMITTAL

Matthew's Story paints as clear a picture as possible of the events of Matthew's life and death. Parts of the story are only sketches, but overall an unmistakable pattern emerges of a boy routinely neglected, and emotionally and physically abused. Through it all, he was not protected -- not by his mother, not by his community and not by those charged with protecting British Columbia's children.

The photographs of Matthew's body taken during his autopsy and filed as exhibits during the Inquiry speak powerfully of his pain and suffering. They show the emaciated, beaten and tortured body of a five-year-old child who died from prolonged neglect and abuse. I have decided not to include any of these photographs in this report. Publishing them would shock members of the community and would, I think, be disrespectful to Matthew.

Matthew's Story and the photographs pose many troubling questions that demand answers. Why did ministry social workers investigate so inadequately the many reports of Matthew's neglect and abuse? Why did medical and child welfare professionals fail, on numerous occasions, to report Matthew's deteriorating condition to the ministry? Should individuals be held accountable for their failure to protect Matthew? Does British Columbia's child protection program need to be reformed, to protect other children from the suffering which Matthew endured?

To answer these questions, I examined what the ministry does when a child in care or known to the ministry dies or is seriously injured. Since 1986, ministry policy has required that the Superintendent of Family and Child Service review such cases and, when the death or injury is suspicious or unusual, refer the case to the Inspections and Standards Unit/Audit and Review Division for a full, independent review.

This review process is a critically important quality assurance function. It is intended to determine exactly what happened, assess the quality of services provided, hold individuals accountable and identify inadequacies in ministry policy or practice that should be corrected. If mistakes were made which contributed to a child's death or injury, the review process should enable the ministry to learn from its mistakes so that children will be better protected in the future.


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