Executive Summary

Report of the Gove Inquiry into Child Protection in British Columbia



How the Ministry Protects Children

Service delivery is the provision of child protection services to children, youth and their families in need of these services. Service delivery may begin with the report of a child in need of protection which leads to intake, investigation, risk assessment, case planning, file transfer and overseeing the delivery of services. The Inquiry found some ministry policies and all ministry practices inadequate in all aspects of the delivery of services.

Provincial legislation requires anyone who has reasonable grounds to believe that a child is in need of protection to make a report of the circumstances to the superintendent or to a person designated by the superintendent.

Anyone who thinks that a child is in need of protection is required by law to report the concern to the Ministry of Social Services. The Inquiry found that for various reasons people do not always report:

The Inquiry concluded that the province's child protection system should further educate the public and the child welfare professions about the circumstances under which child protection reports should be made.

Intake procedure requires that when a ministry office receives a report, a social worker must decide whether it raises a child protection concern or whether it is only a request for voluntary services. In the former case, the report must be investigated, unless the circumstances are exceptional. Surprisingly, about one-third of all protection reports do not lead to an investigation.

An investigation should include interviews with the child, the care-giving parent or parents, other family members and child welfare service providers. The Inquiry found that, although investigation is one of the most complex and demanding aspects of child protection practice, it is frequently assigned to the least qualified, least trained and least experienced social workers.

After completing an investigation, the social worker must do a risk assessment. This requires the exercise of professional judgment in weighing factors such as family history, interactions, relationships, capacities and community supports, and may require psychological and medical assessments. The Inquiry found that the ministry's adoption of a "strengths" approach to service delivery, based on faith in the innate nurturing capacities of the parent, is dangerous in child protection situations, because it focuses on the parent's potential rather than the child's protection.

Risk assessment should lead to case planning. Where the social worker decides that the child is in need of protection, case planning may involve placing the child in the care of the ministry (Superintendent of Family and Child Service), or providing support services to ensure the child's safety in the family home. There is a need for ongoing case planning, as the child's and family's circumstances change. The ministry needs to ensure that all case planning is child-centred.

The ministry has complex policies about the transfer of files, but they are not effective. Such policies are very important in child protection practice: so little information is recorded on the ministry's electronic management information system that social workers need easy access to paper files to inform themselves about previous ministry involvement with a family. The ministry needs to develop a far more comprehensive, purpose-designed computerized management information system for its child protection program.

When the ministry decides that a family needs support services, the ministry's social workers act as "brokers" in negotiating with community agencies to provide these services. The Inquiry concluded that contracts between the ministry and these agencies frequently do not provide enough detail to enable outcomes to be measured. Social workers frequently do not coordinate case plans, monitor performance of contracts or evaluate the quality of service provided by community agencies.

Finally, the Inquiry discovered that there is serious confusion and disagreement within the ministry respecting access to and sharing of important case information. The province's child protection, income assistance and freedom of information and privacy legislation need to be amended so that social workers can access any information necessary to investigate and plan for children.

Quality Assurance

The Inquiry examined existing mechanisms within the ministry aimed at ensuring that child welfare services are delivered competently and with professional integrity. These include supervision of social workers, internal audits, informal reviews, complaint mechanisms and professional regulation.

The Inquiry found that many district supervisors are dissatisfied with the training they receive on case supervision. A 1992 study by the Auditor General found that 40% of supervisors did not do annual performance assessments of ministry social workers. In addition, ISU/ARD is supposed to do a practice audit of every district office every three years, but the Inquiry discovered that the entire audit program was terminated in 1993. The ministry also has no established internal complaints system, and no external mechanism for the review of administrative decisions respecting entitlement to or quality of child protection services.

The Board of Registration of Social Workers, established under the Social Workers Act, has most of the hallmarks of a self-governing professional body, but only about 1,250 of the province's 5,800 social workers are registered. Social workers employed by the ministry are exempt from registration, and only 20% of them have voluntarily registered. Thus, 80% of ministry social workers are not subject to independent professional regulation.

The Inquiry concluded that there needs to be procedures for the automatic review of the plans for children who are in the continuing care of the ministry; a Child Welfare Review Board to ensure that children and their families receive the services that they need; and comprehensive practice audits and performance assessments of workers. The Inquiry also concluded that the regulation of social workers and other child welfare workers should be required by legislation.

Death and Injury Reviews

Reviewing the deaths of and serious injuries to children in care or receiving child welfare services is another important element of quality assurance. The Inquiry found that ISU/ARD reviews of children's deaths were thorough and fair. However, it discovered that in 1992 the then-superintendent terminated ISU/ARD reviews of suspicious or unusual deaths and serious injuries. Since then only two have been completed, Matthew's being one of them.

Equally troubling is a recent Draft Operational Directive, indicating that reviews will in future be done by "excluded managers" (i.e., area managers) in the field. This is troubling since area managers have responsibility for managing the delivery of services and the reviews, if negative, could reflect badly on their management.

The Inquiry called for a new comprehensive and independent system for the review of children's deaths and serious injuries. A new Children's Commissioner, independent of the ministry, should be informed of the death or serious injury of every child known to the ministry, and should decide what form of review is necessary. In "suspicious or unusual" cases, the review should be overseen by a judge of the Provincial Court.

The Children's Commissioner should ensure that death and injury reviews lead to improved service delivery. Patterns and trends identified in reviews and other epidemiological sources should lead to reforms in provincial practice standards, qualifications and training, service design and the delivery of child welfare services.


Of the 25 ministry social workers and district supervisors who had contact with Matthew and who testified before the Inquiry, only eight had a Bachelor of Social Work degree, and none had a master's degree. Province-wide, only 47% of the ministry's child protection social workers have a social work degree.

The ministry is developing a new approach to hiring, known as KSA (knowledge, skills and abilities). It is intended to broaden the base of the recruitment pool, by not insisting on specific educational credentials. The Inquiry concluded that KSA testing can be an important hiring tool, but is not an adequate substitute for a BSW degree. Supervisors should have an MSW degree.

Universities and university colleges should, with appropriate provincial funding, offer a one-year concentrated BSW program for recent BA graduates, and a two-year part-time BSW conversion program for current ministry employees.

Schools of social work should, in consultation with the ministry, review social work curricula to ensure that children's issues, and child welfare issues in particular, receive adequate attention.


A wide variety of professionals need child protection training:

Currently, newly hired ministry social workers are supposed to receive two weeks of training at the ministry's staff training centre in Richmond, one week of orientation in the district office and six weeks of self-study under supervision. The ministry concedes that the existing training program is inadequate. Workers are usually assigned caseloads before they receive training. When they do get training, they are not tested. A recent ministry survey showed that social workers do not feel competent after the training provided by the ministry.

The six-week self-study program presents many of the competencies needed. However, it is ineffective because social workers are assigned full caseloads right away, and supervisors are not trained and do not have the time to oversee the self-study process.

The Inquiry has concluded that, assuming all newly hired social workers have a BSW, the orientation training program should be at least 20 weeks long. Fifteen weeks should be devoted to classroom-based central training, and five weeks to placements in five "teaching offices" where community resource assignments and mentoring can occur.

Testing should be a mandatory part of the training program, and all candidates should be required to reach a minimum passing level in all skills and knowledge.

Ministry provisions for professional development are under-used because the ministry does not normally provide replacement workers, and professional development is not included in the annual performance appraisal system. The Inquiry concluded that ministry social workers should devote 24 hours per year to professional development, and that the ministry should reward employees who take this initiative.

Child welfare service providers in the contract sector provide a wide range of services, but there are no provincial guidelines stating government expectations about qualifications, training or professional regulation. When the ministry contracts with an agency to provide services, it normally does not specify what professional qualifications are required of those who are to carry out the services.

Physicians play an important role in identifying child abuse and in monitoring children at risk. Medical students should be tested for competence in the diagnosis, assessment and follow-up required for all forms of child abuse and neglect. The medical and other child welfare professions need to improve cross-disciplinary approaches to training and professional development.

RCMP and municipal police recruits receive some training in the identification of child abuse and neglect, and in basic interviewing skills. Police and social workers would both benefit from inter-agency training, coordination of services and a better appreciation of each other's roles. The Inquiry found that there is a need for training in regard to the Inter-Ministry Child Abuse Handbook and on information-sharing across agencies. The Inquiry also found that the Inter-Ministry Child Abuse Handbook needs to be updated and revised.

New Legislation: Reviewing the Acts

The Inquiry, in response to a request by Minister of Social Services, the Honourable Joy MacPhail, to make recommendations concerning the Child, Family and Community Service Act and the Child, Youth and Family Advocacy Act, delivered an Interim Report to the British Columbia Provincial Cabinet on March 31, 1995.

On June 7, 1995, the government introduced two amendment Acts which dealt with some but not all of the recommendations made in the Inquiry's Interim Report. In addition, the Inquiry has conducted further research and has proposed other amendments to the acts. These would provide fairness to children and families, improve timely decision-making to aboriginal children and families, improve legislative powers to protect children and youth and make improvements to the clarity of purpose of the Child, Youth and Family Advocacy Act.

Child, Family and Community Service Act

The Inquiry has concluded that children, especially young children under five, should be assured of timely decisions about their futures and that this should be stated clearly by amending the Act so that the early determination of decisions affecting children is paramount and the onus is placed on any other party to show why their interests should reasonably take priority over those of the children.

It is possible for a director to remove a child in need of protection from the parent's care. However, there may be situations in which the director wishes to supervise the care of a child in the child's home but does not want to remove the child. The Inquiry has concluded that the Act should be amended so that a director can proceed by way of summons as an alternative to always having to apprehend and remove a child in order to obtain an order from the court for custody or supervision of a child in the parent's care.

A parent can apply for access to a child in the continuing care of a director. A child 12 and over must be consulted by the director. The Inquiry concludes that all children capable of forming their own views should be consulted and their views should be considered. Also, the child should have the right to make application for access to a former foster parent or parent if the child wishes and the Act should be amended to ensure this.

Aboriginal children, their families and aboriginal organizations have rights of notification and representation at court hearings. However, ambiguities in the definition of an "aboriginal child" may delay proceedings under the Act. In order to determine early in the proceedings who should be notified, the Act should clearly define the meaning of "aboriginal ancestry" and at the earliest point possible in the proceedings, the court should declare whether the child or parent is of aboriginal ancestry so that the appropriate people and organizations can be notified.

The Act states that a child needs protection if the child is likely to be or has been physically harmed, sexually abused or sexually exploited. However, the same provision is not made for the child who is likely to be emotionally harmed. Emotional harm must have occurred and must be demonstrated by the child's behaviour which, according to the Act, must be expressed as severe anxiety, depression, withdrawal or self-destructive or aggressive behaviour. This section should be amended so that children need not suffer emotional harm in order to be protected. They should be protected from the likelihood of emotional harm.

When a director or a social worker delegated by the director to receive and investigate reports receives a child protection report, he or she is required to assess it and then to offer support to the family, refer the family to a community agency or investigate the child's need for protection. The Inquiry concludes that all child protection reports must be subject to an initial investigation, after which family support or a referral may be offered to the family or, alternatively, a further investigation may be required.

The Act permits only a director or delegated representative to initiate child protection proceedings. The Inquiry finds that others interested in a child's safety should be able to begin protection proceedings if, as occurred in Matthew's Story, the child protection officials fail to do so.

The Inquiry has concluded that a director or the director's representative must be able to obtain information necessary to conduct a child protection investigation. This right to information and the ability to compel disclosure should be entrenched in legislation through an amendment to the Act.

A director must refer parents of a child found to be in need of protection to a family conference coordinator. This referral must be made regardless of the child's needs or interests. The Inquiry has concluded that family conferences should not be used for families in which children are at risk of abuse or neglect, and a director should be able to exercise discretion about which families are referred to family conferences.

A provision similar to that which is made in the Family and Child Service Act for the enforcement of custody and guardianship rights when a caregiver refuses to relinquish a child in care should be made in the new Act. There should also be provision in policy for caregivers to have placement decisions with which they disagree reviewed. They should also be given notice prior to the removal of a child from their care.

The Child and Family Review Board has jurisdiction to review breaches of rights of children in care and any other matters referred to it by the minister or by regulation. The Inquiry is concerned that this board is not an adequate review mechanism for appeals, reviews or complaints about child welfare services. Quality Assurance describes a Child Welfare Review Board which has additional powers and which would more appropriately be an external review mechanism for administrative decisions, including service decisions affecting children not in care. The proposed Child and Family Review Board has no such jurisdiction and could not have protected Matthew.

The Act requires that a director file a written report with the court if the director has decided to withdraw a case for child protection. This is presumably so that the court can scrutinize a director's decision. However, there is no provision in the Act for the court to interfere with the director's decision. Either the filing requirements in the legislation should be removed or the courts should be given the power to question and alter a director's decision to withdraw a case for child protection.

Child, Youth and Family Advocacy Act

The Child, Youth and Family Advocacy Act is confusing in that the name of the Act and the description of the functions of the Advocate do not give priority to children and youths interests over the interests of families. The Act should state unequivocally that the Advocate's role is to advocate for children and youth. However, in those instances where the interests of children and youth and their families coincide, it is appropriate for the Advocate to support the family's interests, or indeed adult family members' interests where it promotes the interests of the family's children.

The Inquiry recognizes that the Advocate has jurisdiction over designated services under a designated Act and that, so far, the only Act designated is the Child, Family and Community Service Act. It is anticipated the government will expand the list of designated acts and services over time. The Inquiry concludes that the government should declare its intentions by appending a schedule listing the various designated acts and services which will eventually be brought within the Advocate's mandate, similar to that which is set out in the Ombudsman Act.

At present, the Advocate has no authority to appoint legal counsel to advocate on behalf of a child in a court or administrative proceeding. The Act should be amended to give the Advocate explicit authority to appoint counsel to represent children either individually or collectively as is appropriate.

New Legislation: Reviewing the Acts -- Table of Recommendations (Requires a WWW browser that supports the proposed HTML 3.0 tags for tables (e.g., Netscape Navigator 1.1 or above)

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