Matthew's Story is filled with examples of decisions based on social workers' self-interest, Verna Vaudreuil's interest or the ministry's interest, rather than Matthew's interest. If those decisions had been child-centred, it is likely that Matthew would have been taken into care, either by apprehension or by agreement.
Based on a recommendation in the Inquiry's Interim Report, the new Child, Family and Community Service Act has been amended to state that it must be interpreted and administered so that "the safety and well-being of children are the paramount considerations." This puts children where I believe they should be -- at the centre.
If the legislative concept of child-centredness is followed through in child welfare training, supervision, risk assessments and case planning, then every child welfare decision will be one that promotes the child's safety and well-being. If the social workers who dealt with Matthew and Verna Vaudreuil had come into their positions with professional qualifications and training, they would have been better equipped to identify abuse and neglect risk factors. They would have been better able to understand the underlying causes of Matthew's self-abuse, and to respond to Vaudreuil's serious parenting incapacities.
The recommendations which I have made for the qualification and training of child protection social workers would ensure that, before dealing with clients, these social workers have a grounding in professional social work theory and practice, and an additional 20 weeks of professional training focusing on child protection and child welfare issues.
Academically-qualified and professionally-trained social workers are more likely to have done a proper risk assessment in response to each report about Matthew. They would not have treated each report in isolation, but would have reviewed Verna and Matthew Vaudreuil's files, written a social history, identified Vaudreuil's limitations, and recognized the patterns of abuse and neglect and their detrimental effect on Matthew and his development.
If they had had access to a computerized database containing detailed information about previous investigations, they could have made a much more prompt and professional risk assessment. All of this would have led to more decisive action to protect Matthew, such as apprehension, foster care by consent or some form of intensive long-term in-home support.
If the supervisors in Matthew's case had had adequate qualifications and training, there is a better chance they would have imposed higher standards on social workers in investigating reports of abuse and neglect, making risk assessments and monitoring the delivery of support services. They would also have monitored relevant case information more closely. This could have had a major impact on Matthew: at least one supervisor conceded that he would have considered apprehending Matthew as early as 1989, if he had been aware at that time of a home support worker's description of Matthew's situation.
If a coordinated, multi-disciplinary service model, with community-based Children's Centres, had been in place during Matthew's life, many events would have been different. A Healthy Start primary prevention program would have identified Matthew as at risk because of living in a family with several risk factors and with a parent with limited coping skills. A family support worker would have worked with Matthew and Verna Vaudreuil from his birth to age five to ensure that he was safe. These family support workers, along with public health nurses, home support workers, child development centre staff and consulting psychologists, would have been part of the Children's Centre team, and would have routinely shared information with child protection social workers about Matthew's self-abuse, his delayed development, his mother's poor housekeeping and her chronic neglect of Matthew.
Financial assistance workers and child protection social workers would have coordinated their services. Child protection social workers would have kept the multi-disciplinary team informed about the dozens of reports of Matthew's deplorable living conditions and allegations of abuse and neglect.
If all the different members of the multi-disciplinary team contributed what they knew, a very different picture would have developed about Matthew's safety and well-being. Instead of seeing each event in isolation, the team would have understood the clearly emerging inter-relationship between Vaudreuil's parenting and Matthew's difficulties. That might have led to Matthew being apprehended, being placed in care by consent or being given some form of intensive, long-term, in-home support. No competent multi-disciplinary team, knowing the sum of what individual professionals knew about Matthew, could possibly have approved the inadequate and reactive services that were given to him.
One member of the Children's Centre multi-disciplinary team would have been assigned the responsibility of case manager. That person would have been responsible for bringing all the relevant team members together, pooling their information and expertise and developing a holistic case plan. When it was certain, for example, that Matthew was at risk because of Vaudreuil's abysmal housekeeping, the case plan might have been to bring in a teaching homemaker, to help her learn how to cook and keep the home clean and sanitary. The plan should have set clear, attainable and measurable goals that ensured Matthew was safe and well cared for. If Verna met the goals, then Matthew was, by definition, safe. If Verna did not meet those goals within the stated time period, then Matthew would have been still at risk, and the multi-disciplinary team would have chosen other steps to protect him, including removing him from his mother.
The team's operation out of a Children's Centre also would have given the community in which Matthew and his mother lived a greater voice in deciding what child welfare services would be available for children like Matthew, such as a live-in homemaker. If his community had been encouraged to have a stronger voice during Matthew's life, it is quite likely that his developmental delays, hearing and speech problems and self-abusive behaviour would have been diagnosed and treated earlier.
Had the physicians who treated Matthew during his many office and emergency ward visits been qualified in the diagnosis, assessment and follow-up required for all forms of child abuse and neglect, they might have responded differently. Rather than treating each case in isolation, they might have seen the emerging patterns of neglect and abuse, and the relationship between Vaudreuil's parenting and Matthew's suffering. With that knowledge, they would have been invaluable members of the multi-disciplinary child welfare team. They could have contributed to the identification of Matthew's needs and to the development of coordinated services to meet those needs.
If, during Matthew's life, there had been an effective process for having child welfare decisions reviewed, many of the "no case made" decisions by ministry social workers could have been challenged by those who reported allegations of neglect and abuse, particularly Matthew's father, aunt and uncle. Foster parents could have communicated their frustrations over social workers' failure to consult with them in making decisions about children in their care and could have seen that they were addressed. Verna Vaudreuil herself could have asked that some decisions be reviewed, such as not putting Matthew into temporary care by consent.
Supervisors would have been forced to review more carefully staff decisions made about Matthew's safety and well-being. Independent complaints investigators would have mediated the animosity between social workers and Matthew's relatives, and would have brought a needed degree of objectivity to the review process. The Child Welfare Review Board could have required ministry social workers to demonstrate how their decisions promoted Matthew's safety and well-being and, if they could not, to reconsider the matter from a child-centred perspective.
If the provincial Advocate established under the Child, Youth and Family Advocacy Act had been in place during Matthew's life and was clearly mandated to ensure advocacy for children and youth, it is likely that during multi-disciplinary case conferences someone would have spoken on his behalf. When his interests differed from the interests of his mother, which they often did, an advocate would have ensured that the people making decisions affecting him clearly understood what was best for him.
Had an independent Children's Commissioner been overseeing death and injury reviews, every death or serious injury would have resulted in a report. Systemic failures in the child protection system that contributed to Matthew's death might have been remedied before his death. The Children's Commissioner would have reviewed these reports to look for patterns, and for inadequacies in the qualifications, training, investigative techniques, risk assessments and case planning decisions made by child protection social workers. The Children's Commissioner would have ensured that appropriate action was taken to address the conclusions and recommendations arising from these reports. Being independent from those funding and delivering child protection services, the Children's Commissioner would have pressured the ministry to remedy these inadequacies in a timely way, or would have reported publicly on the ministry's failure to do so.
Almost all the evidence about patterns of parental abuse and neglect and about poor social work practice upon which I have relied in developing the Inquiry's recommendations existed during Matthew's life. Had this information been accessed, analyzed and appropriately acted on, it likely would have led to substantial reforms in the child protection system before Matthew died in 1992. That would have greatly improved the chances that Matthew would have been protected.
Had the provincial government moved decisively to bring together all child welfare responsibilities into a single Ministry for Children and Youth, with the parallel development of multi-disciplinary Children's Centres in each community, it is more likely that Matthew's multi-dimensional needs would have been seen collectively and holistically. The various child welfare disciplines would have contributed to a complete understanding of his needs and his mother's limitations. They would have collegially developed a coordinated case plan to address all his needs, thereby enhancing his protection. There would have been greater capacity for the local community in which Matthew lived to push for specialized services for him.
If the provincial government had exhibited leadership by bringing all child welfare services together at the provincial and community levels, that commitment to child-centredness would likely have transformed the delivery of child welfare services. From the cabinet table to the street, people would have been speaking with one voice for Matthew, and for other children like him. And Matthew may not have died.
I have fulfilled my Terms of Reference and the Inquiry's work is over.
I extend my thanks to the many people who participated in different ways, and who shared their experiences and ideas with me. I particularly want to thank the children and youth who are or have grown up in the care of the ministry. Without their input I would not have had the insight which I believe was necessary to analyze the research and make recommendations.
I also thank the ministry's child protection social workers, a majority of whom wrote submissions to the Inquiry, attended public hearings, participated in workshops or met with me. I visited many ministry offices and I saw first-hand the difficult job we ask child protection social workers to do. I believe that they will be in a better position to do the job that they seek to do -- protect children -- once the changes that I have recommended are made.
Finally, I want to thank the Inquiry staff and research consultants. Seldom have I had the opportunity to work with such a wonderful group of hard-working individuals.
This report is in a form lawful for release to the public. I accept the advice of commission counsel that there are no legal limits on publication or disclosure of information contained in it. I did receive some information during the course of the Inquiry which relates to children and their families and which is, therefore, subject to restrictions on publication. My report contains no information which would identify these individuals.
The issues discussed in my report have received considerable public attention. The public is entitled to know what I have learned during the Inquiry process, and what changes I am recommending in order to protect all of our children. I ask that my report be released to the public immediately.
Thomas J. Gove