1'Need of Protection: Angel?s Story Copyright ® 2018 Manitoba Advocate for Children and Youth All rights reserved. Printed in Canada. ISBN- 978-1-9995410-0-2 Suggested Citation Manitoba Advocate for Children and Youth. (2018). In need of protection: Angel’s story. Winnipeg, MB: Manitoba Advocate for Children and Youth. Who We Are The Manitoba Advocate for Children and Youth is an independent, non-partisan office of the Manitoba Legislative Assembly. We represent the rights, interests, and viewpoints of children, youth, and young adults throughout Manitoba who are receiving, or should be receiving, provincial public services. We do this by providing direct advocacy support to young people and their families, by reviewing public service delivery after the death of a child, and by conducting child-centred research regarding the effectiveness of public services in Manitoba. The Manitoba Advocate is empowered by legislation to make recommendations to improve the effectiveness and responsiveness of services provided to children, youth, and young adults. We are guided by the United Nations Convention on the Rights of the Child (UNCRC) and act according to the best interests of children and youth. TRIGGER WARNING: Please be advised that this report contains information that some readers may find triggering. Angel’s story herein is true to her experiences, but this report may not be suitable for all readers. Please exercise caution. 2 A Special Report published after an Investigation in accordance with Part 4 and Part 5 of The Advocate for Children and Youth Act Dedicated to Honour the Memory of ANGEL 1998-2015 With the exception of the name “Angel,” all identifying information with respect to people and places has been removed to protect the confidentiality and privacy interests of all individuals involved in this special report. Angel’s name is being disclosed with the consent of Angel’s mother in accordance with Section 32(2)(a) of The Advocate for Children and Youth Act. 3 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel?s Story Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Acknowledgements & Dedications ...................................................................................................... 7 Executive Summary ............................................................................................................................ 8 Methodology ................................................................................................................................... 12 TIMELINE ......................................................................................................................................... 15 Angel’s Story .................................................................................................................................... 16 A Critical Period for Family Attachment ........................................................................................ 16 Twenty Placements in Four Years ................................................................................................. 18 A Disclosure of Sexual Abuse and a Mistrusted Therapist .............................................................. 20 Angel’s First Suicide Attempt ........................................................................................................ 25 Solvents, Suicide Attempts, and an Overwhelming Sadness ........................................................... 30 A School That Rallied Supports, But No One Else was Listening ...................................................... 32 A Sexual Assault and an Offender Charged .................................................................................... 40 Clear Signs of Child Sexual Exploitation: Angel’s Addiction Escalates ............................................. 42 “Almost” Sexually Assaulted? ....................................................................................................... 51 Angel’s Final Months: A Trajectory from Trauma ........................................................................... 52 Events Leading to Angel’s Death ....................................................................................................... 54 Events After Angel’s Death ............................................................................................................... 55 Findings, Analysis, and Recommendations ........................................................................................ 56 Manitoba Wide: Adverse Childhood Experiences........................................................................... 56 Manitoba Wide: Sexually Exploited Youth ..................................................................................... 61 Exploitation is Not Being Detected Early Enough ............................................................................................... 63 Sexually Exploited Youth Have Co-occurring Challenges.................................................................................... 65 Child and Family Services.............................................................................................................. 76 Assessment ......................................................................................................................................................... 76 Case Planning...................................................................................................................................................... 79 Service Delivery: Abuse Investigations ............................................................................................................... 81 Service Delivery: Documentation ....................................................................................................................... 84 Service Delivery: Frequency of Contact .............................................................................................................. 85 Evaluation ........................................................................................................................................................... 86 Accountability Within the System: Following the Route of Legislation .............................................................. 87 Addiction and Mental Health Services........................................................................................... 91 Methamphetamine Use is Increasing Among Sexually Exploited Youth ............................................................ 93 Manitoba Lacks Viable Treatment Options for Children and Youth with Life-Threatening Addictions ............. 94 Early Intervention and Prevention are Cost-Effective ........................................................................................ 99 A Note About Recommendations .................................................................................................... 103 5 A Final Thought from the Manitoba Advocate ................................................................................. 104 APPENDICES ................................................................................................................................... 105 APPENDIX A – FINDINGS AND RECOMMENDATIONS ................................................................... 105 APPENDIX B – ANGEL’S PLACEMENTS AND LEGAL STATUS ........................................................... 105 APPENDIX C – ACRONYMS .......................................................................................................... 110 APPENDIX D – TERMS OF REFERENCE .......................................................................................... 111 APPENDIX E - YOUTH DRUG STABILIZATION ACT: INFORMATION FOR PARENTS ........................... 112 APPENDIX F - REFERENCES .......................................................................................................... 114 6 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Angel, age 11 – Photo supplied by the family Acknowledgements The mandate of our office extends throughout the province of Manitoba and we therefore travel and work on a number of treaty areas. Our offices in Southern Manitoba are on Treaty 1 land, which is the traditional territory of Anishnaabeg, Cree, Oji-Cree, Dakota, Ojibwe and Dene peoples, and the homeland of the Metis nation. Our soon-to-be-opening Northern office is on Treaty 5 land, and the services we provide to children, youth, young adults, and their families extend throughout the province and throughout Treaty areas 1, 2, 3, 4, 5, 6, and 10. Dedications This report is dedicated to all of the young people and adults who have been harmed by sexual exploitation. We honour the memory of those who have lost their lives, and we recognize the strength and resilience of all who have been forced to endure this type of abuse. Children, youth, and adults do not choose to be exploited. It is our hope that in telling Angel’s story, we can call on all peoples to remember that children’s lives matter and we cannot continue to look the other way when they are being harmed. Sexual exploitation is an egregious human rights violation that impacts many children and youth in Manitoba and we each have a responsibility to protect all children from this harm. Finally, we honour and thank Angel’s mother for allowing us to tell her daughter’s story. It is difficult to imagine the amount of strength and courage it takes to allow the public to read the details of one’s own family story. Thank you for giving us permission to use Angel’s name and to do what is within our power to build a legacy in Angel’s memory that has the potential to help the many other Angels facing similar struggles in our province today. We honour you and are grateful. 7 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story It is hard to read a story like Angel’s and not feel incredible sadness for what she experienced and endured. From the time she was an infant, Angel was exposed to persistent and ongoing abuse, neglect, and violence, while she witnessed those around her attempt to manage addictions and mental health challenges. Over the course of many years, multiple services were involved or held legal responsibility for care, protection, or service delivery in Angel’s life, and yet, despite extreme and unwavering signs that her family was in crisis, Angel never received the support and protection to which she was entitled and which she desperately needed. The themes in Angel’s story are clear and repetitive. These themes include:  The unimaginable levels of trauma that Angel and her family experienced,  The lack of recognition of the long-term impacts of that trauma,  The need for mental health therapy,  The lack of follow through on multiple recommendations that Angel required mental health supports,  The crushing impact on children when they are sexually abused and exploited,  The failure of public systems to intervene and protect Angel when that need was well known, and  The ongoing lack of safe and secure withdrawal management for youth with life-threatening addictions. In addition to these themes that we discuss in the Findings, Analysis, and Recommendations section of this special report, there were additional patterns in Angel’s story that we note herein. One of these is placement instability. Angel never experienced stability in her life or in her placements. By the time she was 12 years old, she had been apprehended by child and family services (CFS) 14 times, always being returned to her mother’s care, but the required supports to assist the family were never provided. Therefore, with no support or sustained change, Angel would inevitably be apprehended again, once safety concerns reappeared. While she was in care, the guardian CFS agency did not demonstrate any understanding of the impact on a child when being moved so constantly, and the CFS agency continued to move Angel from place to place and community to community. Over the seventeen years before her death, Angel was moved through 46 different placements by CFS, in addition to the times she was 8 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story returned home and then re-apprehended. While these numbers are extreme compared to some other youth our office knows and works with, sadly, they are not so uncommon. Placement instability happens frequently when a child is involved in CFS and this instability has significant and lasting impacts on their abilities to attach in healthy ways to healthy adults, which can leave children and youth at severe risk of detrimental effects and severe negative outcomes. Our public systems must learn more and do better for the children and youth who rely on these systems every day. Predictably, over time, Angel’s attempts to cope on her own with the ongoing trauma began to emerge. These coping strategies manifested outwardly as behaviours that were challenging for service providers to manage. Angel was labelled as disruptive and disrespectful and workers noted that she threw “tantrums” when disappointed or upset. As advocates for young people in Manitoba, it is hard for my team to look at the scope of Angel’s life and not feel exasperated at the sheer lack of compassion and the absence of appropriate service provision provided to her family as a whole, and to Angel in particular. Angel’s family was never provided with an opportunity to succeed. And yet, under the weight of this heart-breaking story, we see rays of hope. We are encouraged by some recent discussions our office has initiated and hosted as we prepared for the release of In Need of Protection: Angel’s Story. Reflecting our commitments to both the true story of a child and to always seek solutions, we have established a multistep practice for how we finalize reports and prepare for their public release. Some of those steps are described in more detail in the Methodology section of this report. As the Advocate for all children and youth in Manitoba, I acknowledge Indigenous political government structures and reach out with offers to meet to discuss pending reports, and their findings, analysis, and recommendations with Grand Chiefs, Chiefs of relevant communities, and their staffs in respect of their inherent rights where public services that have been provided to Indigenous children are being reviewed. Additionally, members of my team and I host system review meetings in the days leading up to the release of a public report, where any organization or department whose files or other information was reviewed during the course of an investigation can come together to discuss the investigation’s findings. It is at these meetings that government departments are invited to provide my office with any additional information (e.g. program updates, etc.) so the report reflects an accurate current context as well as the recent and historical one. It is relevant to share some of my team’s reflections from our most recent series of meetings with provincial government departments. In those meetings with organizations whose involvement in Angel’s life are detailed in the pages of this report, there was common agreement that the ways in which public services interacted with Angel did not properly identify or address her needs or those of her family. In addition, in one meeting, which included senior representatives from the provincial departments of Health, Education, Families, Justice, addictions, and law enforcement, there was a palpable and collective desire to address the gaps that existed for Angel and to make sure services are better for other 9 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story children and youth. Departments spoke up at that key meeting and in the days since to provide important information to our office so that this report and its formal recommendations for systemic changes can be achieved. It is not an easy position to be reviewed by an accountability body like the Manitoba Advocate for Children and Youth, and our office is rarely called in when things are going well for children. The advocacy calls we get, like the death notifications, can follow times where there have been significant breakdowns in the system for a young person, or when a child or youth has died too young. To all who may read Angel’s story, we hope that by the time you turn its final page that you can see achievable solutions are described on these pages and in our final recommendations. While it might be easier to blame a mother who struggled with her own challenges, it is important to understand that all parents love their children and do their best with what they have. When parents are unable to safely care for their children, publicly-funded systems have a role to intervene with understanding, skill, and compassion and those systems should support the family in ways that result in parents being healthy enough again to reclaim their young ones. When public systems are involved in the life of a family, we rightly expect that the public services are fulfilling their responsibilities. Change and growth are not always easy for public systems, which is why these stories of children and youth are so vital. The ability of my office to release these public reports can help move our public systems forward because we are able to identify tangible solutions through the eyes of a child who has experienced the gaps that exist. We acknowledge these reports are difficult to write and difficult to read, however, none of our own fortitude compares when viewed in the shadow of the bravery it takes for a mother to give us permission to use her child’s name and photos. This single act once again lays a mother bare to the prying eyes of strangers. We acknowledge and honour Angel’s mother for allowing us to share this story. It also takes courage for governments to acknowledge deficiencies and then to act. As many of you reading this may know, the legislation that governs my office changed dramatically in March 2018, which has meant exponential growth and change in all areas of my mandate and office activities. The new stand-alone piece of legislation has further galvanized the independence of my office, meaning our ability to centre the voices and experiences of children and youth is further ensured. The power of this new legislation is immense, and its spirit of promoting transparency and accountability of child-serving public systems in Manitoba should give all Manitobans hope. It was a measure of courage as well when all three political parties rose in the Manitoba Legislative Assembly to speak unanimously in favour of the expanded powers of the Manitoba Advocate for Children and Youth. In so doing, our provincial elected officials signalled their commitment to improving services for children, youth, young adults, and all 10 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story families in Manitoba. These changes to my office’s mandate, which are described in The Advocate for Children and Youth Act arose from another child’s story, little Phoenix Sinclair. There are many names of girls and women known throughout the public whose deaths are linked to systemic failures. When spoken, those names are ways we can call on others to never forget their memories of these daughters, sisters, aunties, and mothers. In speaking their names and remembering their legacies, each of us encounter opportunities to do our part to acknowledge the ways in which some people in our communities are systemically disadvantaged. When we remember the girls and women we have lost to trauma-based addiction, violence, and other abuses perpetrated against them, we can acknowledge that as a society we have much road yet to travel before we will reach a place of equity and equal opportunity for all to experience a full and fulfilled life. We share Angel’s story with you today in the hopes that she can also be remembered and inspire the changes that are desperately needed. Rest well, Angel. Respectfully, Daphne Penrose, MSW, RSW Manitoba Advocate for Children and Youth 11 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The Manitoba Advocate for Children and Youth (the Advocate) is notified of all deaths of children, youth, and young adults up to age 21 in Manitoba. The Advocate holds the legal responsibility to assess each death and the discretion to further review or investigate the public services that were, or which should have been, providing support to the young person or their family.1 The Office of the Children’s Advocate (now the Manitoba Advocate for Children and Youth) was notified of Angel’s death on the day she died in September 2015. Following receipt of the official notification, it was determined that Angel’s death was in scope for review because CFS was involved with Angel and her family in the year before her death. As such, formal notification of the Advocate’s intent to conduct an investigation of services was sent to the CFS agency and the First Nations of Northern Manitoba Child and Family Services Authority (known as “First Nations of Northern Manitoba Child and Family Services”). The investigation was assigned internally to an Investigator, and a review was initiated under this office’s former legislated mandate. The Investigator who completed this review requested, received, and subsequently reviewed many sources of information to create a complete picture of the public services received by Angel and her family prior to her death. The services reviewed for this investigation include those provided by:  A CFS agency of First Nations of Northern Manitoba Child and Family Services, which receives its mandate from the Manitoba Department of Families;  The Addictions Foundation of Manitoba (AFM), an agency mandated by the Manitoba Department of Health, Seniors and Active Living; and  Angel’s Middle School, a secondary school under the authority of a School Division of the Manitoba Department of Education and Training. Additionally, files reviewed included the report of the medical examiner and autopsy, as well as records under the authorities of: the Royal Canadian Mounted Police (RCMP); Department of Justice; Department of Families via the CFS agency of First Nations of Northern Manitoba Child and Family Services; Department of Health via the Addictions Foundation of Manitoba (AFM); and Department of Education via Angel’s Middle School and School Division. Originals or copies of written records were reviewed by Investigators either at the organization in question’s office or at the Advocate’s office. 1 See Appendix D, which provides further information about The Advocate for Children and Youth Act (ACYA). For information on the notification process and reports by the chief medical examiner to the Manitoba Advocate for Children and Youth, see The Fatality Inquiries Act, particularly s. 10(1-2). 12 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The Investigator’s request to receive and review federally funded local health services received by Angel in the area of mental health was denied. Given this information was not provided, it was not possible to review the service Angel received in this area. In addition to file reviews, one or more interviews were conducted with Angel’s mother, the CFS agency worker, the CFS agency worker’s supervisor, the CFS agency’s child abuse coordinator, the CFS agency’s foster care supervisor, Angel’s foster parent, the AFM worker for the school division, school social worker, teachers, the assistant superintendent, and several staff sergeants of the local RCMP. Interviews were conducted in person or over the phone. Hand-written notes were transcribed, becoming part of the official record of the Advocate. Over the past year, the Advocate and staff have been in regular contact with Angel’s mother, reaching out to offer support and travelling to her home to spend time with her to gain a more complete understanding of Angel and the events of her life. On March 15, 2018, The Advocate for Children and Youth Act (ACYA) was proclaimed and the scope of the investigation was broadened under the Advocate’s new mandate. Additional notifications were sent about the ongoing investigation and the Advocate’s intention to make this special report public. Formal notification of the investigation was sent to Manitoba Health, Seniors and Active Living, Manitoba Justice, Manitoba Education and Training, and Manitoba Families. Once the Advocate had determined that this investigation would be released publicly as a special report under section 31 of her Act, the above departments were duly notified. Based on the broadened scope of investigation and evidence that emerged, additional file materials were reviewed and further interviews were conducted with RCMP, AFM, the CFS agency, the foster care home, Angel’s school social worker, and education personnel from Angel’s school. In the summer of 2018, the Manitoba Advocate and the Deputy Advocate each met with Angel’s mother. Angel’s mother was offered various support services. She consented to the use of Angel’s name and selected photos of Angel for this special report. On a number of occasions throughout the investigation and writing of this special report, Angel’s mother provided additional information about the family’s perspective on services received and their memories of Angel. That additional information is reflected herein and the Advocate continues to reach out to offer support to the family. In early December, in the interest of administrative fairness, agencies and departments that provided information for this investigation were given an opportunity to meet with the Advocate to review the findings, analysis, and recommendations specific to their service domain area in order to verify the 13 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story accuracy of the information contained herein. An Elder opened these meetings and provided support throughout the discussion with each of the systems. In acknowledgement of the essential voice and value of Indigenous political leaders and governance systems, the Manitoba Advocate extended invitations to Manitoba Keewatinowi Okimakanak (MKO) to the Assembly of Manitoba Chiefs (AMC), and to the Chief of Angel’s home community to meet in order to review this special report and its conclusions. The Advocate, members of her executive team, and a Knowledge Keeper from the Advocate’s office were honoured to meet with representation from MKO, including the Grand Chief, prior to this special report being released to the public. In a separate meeting, the Advocate and her two Deputy Advocates also met with the Chief of Angel’s home community and a Council member. The Advocate acknowledges that there are limitations to this investigation. The accuracy of our evidence relies on the completeness and accuracy of administrative records, the veracity of service providers in the additional information collected from them during interviews, and, when record-keeping is incomplete, the memory recall from service providers who have been involved. While, in many cases, data was verified and cross-checked with multiple sources, this was not always possible. Further, in some cases there was a lack of documentation all together. As noted, in consultation with Angel’s mother, and in accordance with s.32(2)(a) of The Advocate for Children and Youth Act, the Manitoba Advocate has made the decision to release this special report using the youth’s first name, Angel. With the proclamation of the Advocate’s new mandate provided by the ACYA, the Manitoba Advocate is empowered to monitor and report publicly on the level of compliance with recommendations made by the Advocate. Our office is also committed to improving public awareness and opportunities for public education. To that end, the Advocate has initiated processes whereby systems, which receive recommendations for change, will be required to report their progress to the Advocate every six months. Those updates will be analysed by our office and this analysis will be shared publicly so that Manitobans can further monitor improvements in publicly funded, child-serving systems. 14 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story 15 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Angel birth – 2 years of age Angel was born in early summer of 1998. She was the third child born to Angel’s mother, and would eventually have seven younger siblings; Angel’s father had little contact with the family. The family’s involvement with child and family services (CFS) began in 1999, when Angel was 17 months old. Angel, her older brother, and her mother were living in Winnipeg during this time. Angel’s mother’s alcohol misuse and decisions to leave her two children for lengthy periods of time with inappropriate caregivers, resulted in child protection concerns and three separate apprehensions between November 1999 and September 2000. In the first two years of her life, Angel was apprehended three times, by child and family services (CFS) in Winnipeg, and lived in five different placements. According to CFS files, on March 24, 2000, Winnipeg Police Services (WPS) were notified by Angel’s great-aunt that “a fight had broken out” between the great-aunt’s boyfriend and Angel’s mother. It was determined that Angel’s mother had left Angel (age 21 months) in the care of the great-aunt and boyfriend to visit with other relatives. While away from the home, Angel’s mother was told that Angel should not have been left with the boyfriend, as he had previously been convicted of child abuse. Angel’s mother immediately returned home, and when she arrived she found Angel in bed with her great-aunt and boyfriend, and the boyfriend was sexually abusing Angel. Angel’s mother started to fight with the boyfriend, and Angel’s great-aunt called the police. The boyfriend fled the scene before WPS arrived. WPS investigated the witnessed sexual assault against Angel. Angel’s mother and WPS took Angel to a Winnipeg-based emergency room for a medical examination. The examination did not indicate any physical signs of sexual trauma; there were no physical injuries on Angel. WPS informed CFS of the situation, and stated that Angel’s mother was planning to move back to her home community that same day. The CFS worker advised WPS that the information would be provided to the assigned worker for investigation. The file documentation noted that the social worker “made 3 phone calls to the family home. No answer.” There was no further documentation that the CFS agency followed up on the abuse or that it investigated the matter. When we interviewed a Winnipeg Child and Family Services (WCFS), service manager during this investigation, we were informed that in the year 2000, WCFS would have 2 Angel’s full placements and legal statuses are documented in Appendix B. 16 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story referred an abuse investigation of this nature to WPS, rather than conducting one within the CFS agency (Interview, WCFS, August 10, 2015). Despite this previous process for investigations, the CFS agency should have followed up on the concern of leaving Angel with inappropriate caregivers. There was no evidence the CFS agency did so. The offender was charged and convicted with sexual assault and sexual interference. He was placed on the child abuse registry from 2003 until 2013 (communication with provincial Child Abuse Registry, November 13, 2018). Angel and her brother were apprehended again on May 30, 2000, due to her mother’s alcohol misuse and because the children were left with a caregiver who was unable to keep the children for an extended period. On July 18, 2000, at the time of apprehension, a parent and child assessment was conducted. The child assessment described Angel as a bright and playful child, with a possible slight delay in language skills. One area flagged as a concern during the assessment was Angel’s lack of discretion in responding to any adult. The plan for Angel, should Angel remain in care beyond the 3 months, was to visit her mother often, and arrange for a child developmental assessment, however, the plan for a developmental assessment was abandoned because the CFS agency returned Angel to her mother’s care after two months. On September 26, 2000, after Angel’s mother completed addictions treatment, Angel and her brother were returned to their mother’s care, under a sixth month order of supervision. The conditions in place during the order of supervision were for Angel’s mother to maintain her sobriety, attend Alcoholics Anonymous, and complete a parenting skills program. CFS file recordings indicated that between October 20, and mid-November 2000, the CFS worker attended Angel’s family residence on several occasions. File recordings did not document details of these visits, and then, as of mid-November, the CFS agency became unable to locate the family. Due to the conditions of the order of supervision, and the ongoing child safety concerns, CFS in Winnipeg issued a Canada-wide child protection alert on December 4, 2000. On January 11, 2001, in response to the child protection alert, the CFS worker was notified by Employment and Income Assistance (EIA) in Winnipeg that Angel’s mother had contacted EIA for financial assistance, and had provided a Winnipeg address. The CFS worker followed up; however, was still unable to find Angel’s family to check on the children. Angel and her family were finally located in Thompson, Manitoba, on March 29, 2001. A CFS worker based in Thompson connected with Angel’s mother, and then informed a CFS worker in Winnipeg that there were no current protection concerns; however, as the order of supervision was still in place, the 17 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Thompson worker advised the Winnipeg CFS worker that they would continue to monitor the family. Angel’s mother was noted to be pregnant with her fourth child. The six-month order of supervision expired on April 13, 2001, and the case file in a Winnipeg-based CFS agency was closed on May 7, 2001, because the family no longer lived in Winnipeg. At the time of closing, Angel and her older brother were living with their mother; their eldest sister resided with their grandparents under a private arrangement. CHILD AND FAMILY SERVICES INVOLVEMENT (PRIOR TO THE CFS AGENCY OF THE FIRST NATIONS OF NORTHERN MANITOBA CFS AUTHORITY) APPREHENSION 1 (November 1, 1999) DATE ACTIVITY LOCATION November 1, 1999 Placement #1 Winnipeg November 22, 1999 Returned to parent Winnipeg APPREHENSION 2 (March 17, 2000) March 17, 2000 Placement #2 Winnipeg March 21, 2000 Returned to parent Winnipeg APPREHENSION 3 (May 13, 2000) May 13, 2000 Placement #3 Winnipeg May 18, 2000 Placement #4 Winnipeg August 25, 2000 Placement #5 Winnipeg September 26, 2000 Returned to Parent Winnipeg SUPERVISORY ORDER (October 13, 2000 – April 13, 2001) Angel ages 2 – 6 years Almost immediately after the Winnipeg-based CFS file was closed, another CFS agency became involved. This CFS agency would be the one that would provide services to the family from this point in 2001, and on through the rest of Angel’s life. The agency (referred to in the remainder of this report as “the CFS agency”) receives its legal mandate through the First Nations of Northern Manitoba Child and Family Services Authority. The CFS agency first became involved with Angel and her family in May 2001, just prior to Angel’s third birthday. The family came to the attention of the CFS agency because of Angel’s mother’s alcohol misuse, and leaving the children in unsafe situations. Between May 2001, and June 2005, Angel and her two siblings were in and out of care and placed in various homes in Community #1 and Community #3. During this period, Angel had five siblings, ranging in age from 7 months to 11 years. A pattern emerged whereby Angel’s mother would experience a relapse from sobriety, resulting in her children being apprehended due to protection concerns, and then the children would subsequently be returned by the CFS agency to her care. Angel’s mother would willingly undergo and complete treatment for her substance misuse with the goals to remain sober, and to live with and raise her children in a stable home. However, Angel’s mother’s treatment attempts for her alcohol misuse did not work for her. 18 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story She had experienced childhood trauma, and without sustained opportunities for healing, Angel’s mother was unable to reach her goals for household and family stability, which resulted in continuous disruption and instability for the children, itself another form of trauma. During these four years, Angel was apprehended six times, lived in 26 placements, and was returned to her mother’s care on seven occasions. Over those four years, there were also five different workers from the CFS agency involved with Angel and her family, which would have compromised the CFS agency’s ability to establish an ongoing rapport with any of the family members. While workers can change on a file for numerous reasons, including: a family move, staff turnover, or a change in status in care, a change in worker should not compromise the quality of services provided to a family. Families involved with CFS have the right to expect that service delivery decisions are being made in the best interests of the family, and that assessments and case planning address both immediate needs as well as long term goals and objectives. Unfortunately, our investigation revealed the CFS agency did not follow or meet minimum provincial service standards in numerous areas, including: assessments, case planning, service provision, and evaluation. Two case plans were located on the file, dated December 13, 2004, and June 13, 2005, when Angel was five and then six years old. The case plans focused on Angel’s mother and her treatment needs, and did not identify or properly assess the needs of the children. The CFS agency did not consider the impact that these numerous apprehensions, placement changes, and returns home had on Angel and her siblings. The case plans did not identify a specific reunification process or the support needs for the family, only that Angel’s mother continued working with the CFS agency for counselling related to her own issues. Angel’s mother lived with chronic substance misuse and there was no acknowledgement by the service providers active in the family’s life that the ongoing and severe substance use created significant safety risks for Angel and her siblings. The CFS agency did not undertake any case planning that aimed at sustained improvements for the family’s situation, and the CFS agency did not seek family or community members to provide safe care for the children while they knew Angel’s mother continued to struggle. Instead, this CFS agency returned the children repeatedly without conducting any assessments, without providing any support, and without assessing Angel’s mother’s capacity to parent. DATE May 14, 2001 May 16, 2001 May 26, 2001 June 6, 2001 July 24, 2002 July 30, 2002 August 30, 2002 INVOLVEMENT WITH THE CFS AGENCY ACTIVITY APPREHENSION 4 (May 14, 2001) Placement #6 Placement #7 Placement #8 (Kinship) Return to parent APPREHENSION 5 (July 24, 2002) Placement #9 Return to parent Placement #10 19 LOCATION Community #1 Community #1 Community #1 Thompson Community #3 Community #3 Community #3 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story September 1, 2002 September 5, 2002 September 28, 2002 September 29, 2002 October 3, 2002 October 17, 2002 February 20, 2003 February 25, 2003 May 10, 2003 May 12, 2003 May 13, 2003 May 14, 2003 June 5, 2003 June 22, 2003 June 23, 2003 June 26, 2003 July 9, 2003 August 7, 2003 March 24, 2004 March 30, 2004 July 6, 2004 Placement #11 Community #3 Return to parent Community #3 Placement #12 Community #3 Placement #13 Community #3 Placement #14 Community #3 Return to parent Community #3 DISCHARGED (January 7, 2003) APPREHENSION 6 (February 20, 2003) Placement #15 (same as #14) Community #3 Return to parent Community #3 DISCHARGED (February 25, 2003) APPREHENSION 7 (May 10, 2003) Placement #16 Community #3 Placement #17 Community #3 Placement #18 (same as #16) Community #3 Return to parent Community #3 DISCHARGED (May 14, 2003) APPREHENSION 8 (June 5, 2003) Placement #19 Community #3 Placement #20 Community #3 Placement #21 Community #3 Placement #22 Community #3 Placement #23 (Kinship) Community #1 Return to parent Community #1 DISCHARGED (August 7, 2003) APPREHENSION 9 (March 24, 2004) Placement #24 Community #1 Placement #25 Community #1 Placement #26 Community #1 3 MONTH TEMPORARY ORDER (September 13, 2004) 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (December 13, 2004) 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (March 13, 2005) 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (June 13, 2005) Angel ages 7 – 11 Angel was exposed to numerous adverse childhood experiences between the ages of seven and 11. Her mother continued to attend and complete treatment programs for her chronic addiction issues, which were followed by relapses, resulting in the children being apprehended by The CFS agency for protection reasons, and then the children being subsequently returned home by the CFS agency to repeat the cycle over and over again. While the CFS agency was aware that Angel’s mother struggled to parent in safe and healthy ways, it continued to place the children back into their mother’s care without assessments, planning, or appropriate supports that would have helped Angel and her family address their challenges and change their trajectories. 20 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The CFS agency case plan dated September 13, 2005, noted that Angel’s mother was in a residential treatment centre in a northern Manitoba community. A further case plan located on the CFS file, dated November 2005, noted that Angel’s mother had completed the treatment program, and Angel and her siblings were returned by the CFS agency to their mother’s care in Community #1, on November 1, 2005. The CFS agency’s file closing form documented that Angel’s mother was “doing good” and attended programs in the community. Angel and her family were noted to be living at the local crisis centre until housing was able to be secured. The CFS family services file was to remain open for “monitoring.” The CFS agency did not describe what “monitoring” would include, and there was no evidence that any further support was offered to the family at this time. On March 19, 2006, Angel (age 7) disclosed to a nurse in Community #1, that she had been sexually abused. Angel, her siblings, and their mother were still awaiting housing in the community and were now living at the local healing centre. Angel disclosed that her mother had left Angel’s siblings and her in the care of a resident of the healing centre while her mother was out. Angel said that the caregiver had fallen asleep and that another resident had come into Angel’s room and sexually assaulted her. Angel’s nine year old brother was reported to have been a witness to the sexual assault. Royal Canadian Mounted Police (RCMP) in Community #1 were notified by Angel’s mother, and Angel and her mother were flown to Winnipeg where Angel was examined by a physician from the Child Protection Centre (CPC). The day after the assault, on March 20, 2006, the CPC wrote the assessment and recommendations for supporting Angel and her family. During the assessment, Angel’s mother had reported that she lacked appropriate supports and believed there was “little assistance on the reserve for Angel,” and that she did not “trust the therapist” who was from outside the community and attended Community #1 on a weekly basis. Angel’s mother stated she would not be comfortable sending Angel to the therapist for mental health support, as Angel’s mother did not trust that confidentiality would be maintained. The CPC sent the following assessment and recommendations to the CFS agency: 1. Although she acted in a protective manner once she became aware of the alleged assault against Angel, [Angel’s mother] acted in an impulsive manner when she left the children in the care of [offender name removed]. Her ability to protect her children from future similar occurrences is questionable. It is recommended that [Angel’s mother] receive parenting education. 2. The agency appears to have taken the proper steps in investigating the alleged abuse and protecting the children. 3. Angel was allegedly sexually abused and is therefore in need of counselling services. Specific treatments are recommended such as Families Affected by Sexual Assault Program or Sexual Abuse Program (both Winnipeg based). In the event that the children are placed in or around the Thompson area, the RCMP Victim Services Unit can be accessed. 21 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story 4. [Angel’s mother’s] abuse history appeared to be unresolved. She would benefit from individual treatment. Treatment will also assist her with her capacity to support Angel. 5. [Angel’s mother] was provided a handbook regarding the dynamics of sexual abuse and community resources if needed. 6. Finally, this writer feels the need to make mention of [3 of Angel’s siblings]. According to [Angel’s mother] her relationship with [previous partner] ended as a result of domestic violence. She also stated that their children reside in the care of their father. In light of this information, it is recommended that the well being of the children be assessed by the appropriate CFS agency. The CFS agency conducted an abuse investigation in response to the sexual assault. The safety assessment noted that Angel’s mother had not acted protectively because she “left her children with the offender,” although this conclusion did not reflect that Angel’s mother had actually left the children with a caregiver who was not the offender. Still, it was determined by the CFS agency that Angel would have bi-weekly sessions with the mental health therapist, a six-month order of supervision would be put in place, and respite supports would be implemented to support Angel’s mother as she cared for the children. Notwithstanding these CFS agency plans, there was no evidence of a parental capacity assessment, no risk assessment, and no safety plan located on the CFS agency file during the investigation by our office. Further, there was no evidence that any of the recommendations made by the Child Protection Centre were completed by the CFS agency: no parenting education, no counselling for Angel or her mother, no safety assessments completed for the other children living with their dad who was noted to be violent. On April 4, 2006, Victim Support Services (VSS) sent a letter to Angel’s mother offering child Victim Support Services, which assists child and youth victims of abuse and their families in cases where criminal charges have been laid. Support offered to the child and their family includes:  Providing child and family with information and support  Telling child and family about how the court system works  Helping child understand what s/he will need to do, if required to attend court  Attending court with child and family, when possible  Providing child and family with information about other services that may be helpful After four attempts to contact Angel’s mother, the child victim worker spoke to Angel’s mother on August 29, 2006. Angel’s mother informed the VSS worker that she was more concerned about seeing the accused, and the VSS worker encouraged Angel’s mother to maintain contact with victim support services. On September 6, 2006, the VSS worker met with Angel (age 7), and reviewed the video statement she had provided detailing the assault. The Crown entered the video statement as part of its evidence in court. At the conclusion of the trial, the offender was convicted of sexual assault. The victim 22 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story support services file was closed in June 2007. Whether the offender was sentenced to custody was not noted by CFS on their file. On August 22, 2007, the convicted offender was placed on the Child Abuse Registry (communication with provincial Child Abuse Registry, November 7, 2017). On May 18, 2006, during the time when the sexual assault was being criminally investigated and addressed, a six-month order of supervision was obtained by the CFS agency. The June 14, 2006, case plan located on file noted that “sexual assault to child has had a devastating impact,” with the goal for Angel’s mother and the children to start seeing a mental health worker. Angel’s family relocated to Thompson, Manitoba, on June 22, 2006, in an attempt to secure housing, however, on July 17, 2006, they returned to Community #1. A file transfer summary on the CFS file noted that Angel had not seen a mental health worker in Thompson due to their short stay. And, despite no evidence that therapy was being provided for Angel, the CFS file transfer summary noted that in order to “continue” therapy in Community #1, “building trust” was needed. Angel’s mother was noted to be supportive of mental health intervention for Angel, but her mother also said she did not want to “push” Angel into therapy. There is no evidence that mental health support was subsequently provided to Angel. On February 4, 2007, The CFS agency intake received a referral stating that Angel (age 8) and her siblings had been left alone during the night by their mother. The four children ranged from ages one to ten years old. The CFS agency workers went to the house where they located Angel’s mother, and they described that it was “evident that she had been drinking.” The children were apprehended by the CFS agency and taken to their maternal grandmother’s home. Follow-up by the CFS agency indicated that Angel’s mother continued to misuse alcohol; however, she was willing to access local support services in order to continue parenting her children while she worked to refrain from misusing alcohol. Angel’s mother agreed to mental health therapy for herself; there was no mention by the CFS agency of Angel’s ongoing need for mental health therapy. The CFS agency documented that their file would remain open for three months to monitor and support the family, however, there was no further documentation outlining what the support or monitoring would look like, or if any monitoring actually occurred. The children were returned to their mother two days after being apprehended, with the CFS agency file closing form stating that Angel’s mother had the “determination and willingness to have a positive lifestyle with her children and she is not afraid to seek or ask for help or support services.” 23 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story According to a letter which was later sent by the mental health worker to the CFS agency, Angel was taken to the nursing station on April 17, 2007, when she was found having wrapped the sleeves of her sweater around her throat “to get dizzy” (Letter from the mental health therapist located on the CFS file, dated May 16, 2007). The mental health therapist indicated they had met with Angel that same day, and counselled her on the risks involved with that behaviour. An The CFS agency intake form, dated April 24, 2007, indicated that Angel’s mother brought Angel’s sister (age 15 months) to the nursing station because she was worried the child may have accidently ingested some fuel that was being collected in a cup from the furnace fuel drip in the home. CFS files indicate that Angel’s sister lives with special medical challenges and required scheduled medication to be administered. During this contact at the nursing station, it was learned that Angel (age 8) had been caring for her siblings while Angel’s mother was out and also that Angel had expressed suicidal thoughts to a school employee. The CFS file documented that Angel’s mother’s alcohol misuse had continued, and she was leaving Angel as the caregiver for her siblings. The safety assessment completed by the CFS agency deemed the children unsafe, and they were apprehended. Angel and her brother were placed with her maternal grandparents, and Angel’s younger sister was sent to Thompson for medical follow up and placement. There were no case plans completed for the family. Angel had a follow up appointment with the mental health therapist on April 24, 2007, the same day as the nursing station visit regarding the furnace fuel. Angel revealed that she was distressed by her mother’s alcohol misuse, her mother not coming home at times, and being left to look after her siblings. Angel was described by the therapist as withdrawn, unhappy, and introverted. The May 16, 2007 letter written by the therapist to the CFS agency included the following recommendations: Angel appears to be suffering emotionally, physically, mentally and spiritually. She is at risk of repeating suicidal intent if her situation continues. I [mental health worker] would encourage a home assessment (perhaps several visits) to monitor wellness of [Angel’s mother] and her children. Angel has not returned to see me [mental health worker] for follow up counselling; this needs to be encouraged. The CFS agency took no action in response to the recommendations made by the mental health worker. With no documented supports in place for the family, the CFS agency returned Angel to her mother’s care on May 7, 2007. File recordings stated that that the case plan accomplishments were that Angel’s mother had accompanied Angel to the mental health therapist, Angel’s mother had a caregiver for her children when she went out, and the maternal grandparents were supportive of the family. The reason for file closure stated by the CFS agency was that the April 25, 2007, allegation of Angel’s mother leaving her children unattended was unfounded, despite direct information told to them by Angel. File documentation did not indicate how the CFS agency determined or properly assessed this conclusion. 24 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story On May 25, 2007, two weeks after being returned home, Angel (age 8), contacted the CFS agency intake and asked for help regarding her mother’s alcohol misuse and the children not being properly cared for. The children were removed from their home and placed in a kinship arrangement with their maternal grandparents in Community #1. When the worker met with Angel’s mother on June 20, 2007, Angel’s mother minimized her alcohol use as a concern and said that Angel was acting out due to her jealousy of her younger sibling. Angel’s mother also said that, in her opinion, Angel was not ready to deal with the sexual abuse incident that had occurred in 2006, and stated that Angel’s mother did not trust the mental health therapist, noting “[the therapist] exaggerates.” Angel’s mother further stated the “children will get apprehended if they take them to the therapist.” There was no evidence the worker met with Angel regarding the concerns she had reported to the CFS agency. A safety assessment was conducted by the CFS agency, and the children were deemed safe, as the CFS agency determined there were no children likely to be in immediate danger of moderate to severe harm at that time. The CFS agency returned the children to their mother’s care on the same day, June 20, 2007. The safety plan indicated the CFS agency needed to monitor the family and the children, “especially Angel & [her younger sister].” There was no evidence on agency files describing their plan for “monitoring” or that any further action was taken by the CFS agency. A case plan dated July 31, 2007, indicated that the CFS agency believed Angel’s mother needed to accept responsibility and make decisions that would allow her to parent more safely and effectively, and that Angel and her mother needed to remain together. The CFS agency’s plan was for the CFS case worker to “initiate relationship and create an open communication” and to utilize “local resources.” The CFS agency did not offer any support services to the family for nearly two years, and then on January 16, 2009, Angel’s “out of control behaviour” was documented on an intake form completed by the CFS agency. Angel’s mother had called the CFS agency for support and the CFS agency recorded that Angel, “nearly burnt house down. Angel does not listen in school.” The worker met with Angel’s mother, and learned that Angel had been living with her mom, and two siblings, while Angel’s remaining four siblings were not in their mother’s care at that time: one sibling was living with the maternal grandparents, one sibling was in care of the CFS agency, and her other two siblings were living with their biological father. Due to Angel’s behaviour, Angel’s mother had arranged for Angel (age 10) to move to Community #7, to live with a relative under a private arrangement. Angel’s mother informed the CFS agency worker that if this private arrangement broke down and Angel moved home, she would be needing support services to manage Angel. 25 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The CFS agency did not document any further involvement with the family at that time. At some point between January and September 2009, Angel moved back to Community #1, and on September 2, 2009, the CFS agency apprehended Angel as she was using solvents, was self-harming, and the cutting injuries to her wrists at the time were believed to have been a suicide attempt. She was flown to Winnipeg for a mental health assessment and admitted to an inpatient child and adolescent mental health program, from September 2 - 6, 2009. Agency file recordings stated that Angel was leaving the house at night, sniffing gasoline and wood glue, and was not attending school. The CFS intake worker spoke with Angel, who said: She does not like it in [Community #1] and she will continue to sniff and sneak out. She gets teased at school, she can’t read or write. Kids make fun of her looks the way she dresses and talks. She forgets all of that when she sniffs. The worker told Angel that she would be apprehended and “come under care” but Angel “must listen to her mom until [the CFS agency] secure[s] a placement for her.” Back in the community, a safety assessment was conducted by the CFS agency that same date, as four of Angel’s siblings were living with their mother. The CFS agency deemed the four siblings safe to live with their mother, with the reason that they were all younger then Angel, and their mother “had control of them.” CFS documented that Angel’s mother’s parenting skills were “good” and that she was not afraid to ask for support. This determination by the CFS agency was made with no assessments completed, and seemingly no acknowledgement of the abuse, neglect, sexual assaults, and chronic addiction issues through which the family had lived for the previous decade, of which the CFS agency was fully aware. During her stay at the inpatient mental health unit, Angel received the diagnoses of adjustment disorder and solvent abuse, and was directed to follow-up with the community mental health worker. CFS file documentation noted that Angel was considered ready for discharge from the hospital as long as there was a plan for her. CFS file recordings stated that the plan was to move her to a foster home in Community #6, where her eldest sister lived. Angel was placed in that foster home upon discharge from the inpatient mental health unit on September 7, 2009. The CFS file reflects that the CFS agency supervisor documented that Angel needed to receive mental health services and supports. There is no evidence that any mental health supports were arranged at this time. The CFS agency case plan dated October 1, 2009, noted that Angel (age 11) needed support and encouragement, stability in the foster home, confidence to attend school, and that she her past sexual abuse needed to be addressed. A respite worker was provided one hour each day to assist Angel with her homework. There was no indication that the CFS agency followed through with the other support 26 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story needs described in the case plan and Angel received no intervention to address the multiple incidents of sexual abuse she had experienced or her ongoing mental health concerns. A six-month temporary order of guardianship was granted to the CFS agency on October 21, 2009. There were two separate monthly foster parent contact sheets completed on file, dated October 1, 2009 and December 2, 2009. It was documented that Angel was having a difficult time settling, and there were health concerns. The December 2, 2009 foster parent contact sheet documented Angel (age 11), was “hard to handle,” “very disruptive,” and “not following rules.” When asked about Angel’s health, it was documented that, “Infections on vaginal area. Medication given. Always complaining of sore lips also bladder problems.” There was no further documentation indicating that the CFS agency recognized this as a significant warning sign, and there is no indication that the CFS agency initiated an investigation regarding possible sexual abuse or sexual exploitation. There was no follow up by Angel’s worker. From December 14, 2009, to January 7, 2010, Angel (age 11) went to Community #1 to spend the holidays with her mother. File documentation did not indicate if safety planning occurred between the CFS agency staff, Angel, and Angel’s mother to ensure Angel’s safety during the visit. Upon her return, Angel’s respite service provider documented on the January 8-9, 2010 weekly time sheet for the CFS agency that, “…[Angel] said she sniffed all the time she was at home. Her nose looks sore and she is coughing lots again.” There was no follow up by Angel’s worker to the information from the foster parent. Angel’s respite service provider next documented on the weekly time sheet dated January 10-16, 2010, that, “Angel said she sees a man all in black when she wakes up. She said she is scared to sleep alone but mom won’t let her sleep on the bed with someone…[Angel] said she likes to sniff because it makes her feel good when she is scared…” There was no evidence Angel’s worker followed up on this additional concern documented by the foster parent. The January 26, 2010, CFS agency case contact sheet identified that the CFS worker had face to face contact with Angel. There is no evidence that the worker addressed any of the warning signs and concerning details being documented at that time in the foster home and in relation to Angel’s recent visit home. Instead, the notes by the CFS worker stated, “Angel is feeling good today, she is all smiley and loves to gab. She loves being at [foster parent’s], it clean [sic] and they have fun…no health concerns, currently healthy.” The February 1, 2010, monthly foster parent contact sheet documented that, “[Angel] continues to be bothered with her private area. Gets sore and red. Medication has been prescribed. She has many nightmares and has a problem sleeping.” Again, there was no response or follow up by the CFS agency to these documented warning signs of possible sexual abuse or sexual exploitation. 27 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Angel’s respite service provider documented on the weekly time sheet, dated March 1-6, 2010, that, “Angel said she is still bothered over the guys that touched her and that her mom doesn’t believe her.” On the weekly time sheet for the CFS agency, dated March 7-13, 2010, Angel’s respite service provider documented that, “Angel is asking about Easter holidays. I [respite worker] told her that [foster parent] will let her know when they will be going home. She said she wants to go home for a visit but wants to go to school here until it is finished.” The following week, Angel’s respite service provider documented that, “Angel is worried because her mom says that she has to go home now and not come back…she feels if she has to go home she says the girls will fight her and she is not ready to start sniffing again.” On the next time sheet for March 21-25, 2010, Angel’s respite service provider wrote, “Angel knows she is going home now. She is happy and unhappy. I [respite worker] told her that mom is right when she says the best place for her is with her mom. I [respite worker] told her she learned lots by being here and that she can show her family.” There was no evidence that the CFS agency had made any attempt to address the previously identified concerns including Angel’s mother’s addiction, her capacity to parent the children, Angel’s mental health, the ongoing impact of the sexual abuse, Angel’s self-harming, her concerns about returning to Community #1, or the warning signs of possible ongoing sexual abuse or sexual exploitation. With no reunification plan, or assessments documented on file, on March 26, 2010, Angel (age 11) and her older sister (age 14), were returned by the CFS agency to their mother in Community #1. File records did not indicate if any of Angel’s other siblings were living with their mother. The CFS agency’s case closing form stated that Angel’s mother had abstained from alcohol for over four months, she had secured a house, and was working. The closing notes also described that Angel had attended school regularly and had made friends, and claimed that Angel had stopped sniffing solvents since being in care. Despite the significant documentation of the respite worker to the contrary, CFS file recordings indicated that during Angel’s last two home visits she listened to her mom, remained free of solvents, and abided by her set curfew. Angel’s mother told the CFS agency that she was willing to work with them and utilize the necessary supports if she encountered any problems. The suggested plan was for Angel to start seeing the local mental health therapist. Even though the CFS agency would, in two weeks’ time, still be involved, the CFS agency closed their file March 26, 2010, the same day the children were returned home. On April 13, 2010, the CFS agency sent a letter to the mental health therapist in Community #1 requesting therapy for Angel, and asking for updates as the therapy progressed. 28 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story On April 19, 2010, Angel’s mother wrote a letter to the CFS agency stating, “Since Angel came home, she has been wanting to go back to [CFS] care. [Angel] goes out sniffing gas all night. And we have to go out looking for her.” The therapist from Community #1 wrote a letter to the CFS agency on May 10, 2010, providing a therapy update. The therapist spoke to Angel’s mother who indicated that she was concerned that Angel was “beginning to slide back into past behaviours.” Angel did not show up for the May 9, 2010 therapy appointment that was made for her. The appointment was rescheduled for June 1, 2010, however, Angel did not attend that one either. Another appointment was made June 29, 2010, and again Angel did not attend. The CFS agency was notified by letter of the attempts made by the therapist to provide therapy for Angel. There was no documentation presented for review during this investigation describing how the CFS agency responded to the letters provided by the therapist from Community #1. During this five year period, from June 2005 to June 2010, Angel was apprehended four times, lived in five placements and was returned to her mother’s care on five occasions. To date this meant Angel had already lived in 31 separate out-of-home placements before she reached age 12. The CFS agency repeatedly initiated reunification without conducting any of the required assessments, without providing any meaningful interventions or support, and without assessing Angel’s mother’s parental capacity, which they knew to be of significant concern. The CFS agency did not acknowledge or recognize warning signs when Angel presented with signs of sexual abuse, sexual exploitation, and solvent use, when she shared her fears about home visits with CFS agency workers, and child abuse investigations did not occur when they were required. Minimal documentation was completed during this period, and provincial case management standards, which describe the minimum required actions for CFS agencies were not met in any of the required areas of assessment, planning, service provision, or evaluation. During this time, the need to address Angel’s mental health challenges was recommended by three separate health professionals who assessed Angel, and while the CFS agency acknowledged that Angel did indeed require mental health services, there was no evidence in the CFS agency’s recordings that Angel’s therapeutic needs were addressed. DATE March 30, 2006 February 4, 2007 February 6, 2007 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (September 13, 2005) DISCHARGED FROM CARE (November 1, 2005) APPREHENSION 10 (March 30, 2006) ACTIVITY LOCATION Return to parent Community #1 6 MONTH ORDER OF SUPERVISION (May 18, 2006) DISCHARGED FROM CARE (November 18, 2006) APPREHENSION 11 (February 4, 2007) Placement #27 (Kinship) Community #1 Return to parent Community #1 29 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story April 24, 2007 May 7, 2007 May 25, 2007 June 20, 2007 September 6, 2009 September 7, 2009 March 26, 2010 DISCHARGED FROM CARE (February 6, 2007) APPREHENSION 12 (April 24, 2007) Placement #28 (Kinship) Community #1 Return to parent Community #1 DISCHARGED FROM CARE (May 7, 2007) 1 MONTH VOLUNTARY PLACEMENT AGREEMENT (May 25, 2007) Placement #29 (Kinship) Community #1 Return to parent Community #1 DISCHARGED FROM CARE (June 20, 2007) APPREHENSION 13 (September 2, 2009) 6 MONTH TEMPORARY ORDER (September 24, 2009 – March 23, 2010) Placement #30 Thompson Placement #31 Community #6 Return to parent Community #1 DISCHARGED FROM CARE (MARCH 26, 2010) Angel 12 – 17 years of age As one would predict, when Angel entered her teen years, she struggled with school attendance, suicidal thoughts, suicide attempts, drug misuse, mental health concerns, and she was sexually exploited, frequently missing, and had come to the attention of the youth justice system. The unresolved trauma that Angel experienced from birth manifested in predictable behaviours, which were born from having been subjected from infancy to severe trauma and structural risk. On August 5, 2010, Angel (age 12), attempted to hang herself. She was found in time and flown to a Winnipeg-based hospital emergency room for assessment; medical records stated that she was admitted to an acute adolescent psychiatric ward on August 6, 2010. Angel informed medical professionals that she felt unsafe in her home community, that she experienced “threatening statements from other children,” that she had been thinking of a homicide death of a boy that had happened in her community, and she described feeling unloved by her family. Angel described significant substance abuse by herself and her family members. While in the acute psychiatric ward, Angel was referred to occupational therapy so her coping skills could be assessed. The occupational therapy report dated August 12, 2010, noted that Angel reported that she spent most of her time in the past year sniffing gasoline “with anyone I could find.” She reported not attending school for more than one year and she was unable to identify any friends. Angel indicated that she was often the target of bullying in the community and spoke of feeling disconnected from others. Recommendations made by occupational therapy included: 30 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story  Further assessment is recommended to determine supports required to meet Angel’s learning needs.  Further assessment and intervention in the area of social skills and teaching personal boundaries and instilling personal values will be important.  Further assessment in the area of sensory processing by an outpatient Occupational Therapist would be recommended.  Angel would benefit from being enrolled in active recreational options.  Angel should be encouraged to participate in active plan on a daily basis.  Further investigation to determine if Angel’s mother used alcohol during pregnancy may be warranted to determine if referral to the Manitoba Fetal Alcohol Spectrum Disorder Clinic may be warranted for diagnostic purposes which may open the door to further supports for Angel. The August 16, 2010, CFS agency amended case plan documented that Angel needed mental health therapy, a referral to an addictions program, and a stable foster home. There was no indication on file that the CFS agency followed through with providing any intervention or support for Angel with respect to the recommendations made while Angel was a patient at the mental health unit. Following her discharge from the mental health unit, Angel was placed in a foster home in Winnipeg. The CFS agency worker met with Angel at the foster home, on August 18, 2010. Documentation noted that Angel needed clothing and school supplies. The foster parent had bought a kitten for Angel. Angel was reported missing to Winnipeg Police Service (WPS) by Angel’s foster parent, on August 22, 2010. She was located that same day (Winnipeg Police Service documentation, May 20, 2016) and taken back to her foster placement. On August 23, 2010, “Angel attempted to hang herself with her [pyjama] bottoms.” The foster parent intervened, and Angel was taken to a crisis stabilization facility in Winnipeg by WPS. She was discharged from the facility on August 27, 2010. The CFS agency case plan also dated August 27, 2010, identified the presenting problem as:  Past sexual abuse  Negative coping skills  Suicide attempts  Impulsiveness  Lack of school attendance  Poor self-esteem  Possible fetal alcohol spectrum disorder, and  Being beyond the control of parents/guardian. 31 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Her needs noted by the CFS agency included: a stable foster home, structure and routine, mental health counselling, and a referral to an addictions program for her solvent abuse. While some of Angel’s challenges and needs were documented at that time by the CFS agency, concrete plans identifying services for Angel were not provided. Further, there were no assessments completed at this time and documented on file. It is not clear that the CFS agency understood that these were predictable outcomes of the trauma and abuses Angel had survived and which had been allowed to grow unaddressed and unresolved despite the fact that the agency had been involved in her life since she was 17 months old. On August 27, 2010, Angel, age 12, was moved by the CFS agency to a foster home in Community #4, where she would live for three and a half years. The home was in the process of being licensed by the CFS agency when Angel moved in. The CFS agency placement information form indicated that Angel should be placed “in a healthy, structured foster home where she get lots of one on one and mental health services…” The expectations the CFS agency had of the foster parent were “to nurture, provide guidance, stability, structure and ensure [Angel] attends school and attend mental health appointments.” Angel’s strengths and interests were identified as: “…easy to talk to, she is adaptable and can express herself well. Loves attention, music, computer and loves compliments.” There were no concrete plans documented on file, indicating particulars of the mental health appointments that the CFS agency documented as both a need for Angel and an expectation of the placement. Angel attended middle school in Community #4, within that community’s School Division, for grades 6, 7, 8, and 9, from 2010-2014, with the exception of January to May 2014, when she was moved by the CFS agency to a different community. School staff described Angel as loud, vibrant, and honest. She was viewed as a very authentic person, compassionate, and could bring out the best in people. Staff also recognized Angel as someone who would withdraw at times. She was known as a gifted artist and writer (interview, school staff, June 6, 2018). The school quickly recognized that when she arrived, Angel required immediate, ongoing, and constant support. She had a team of people who supported her learning needs, and advocated for her: two guidance counsellors, the school social worker, and her teachers. Angel had access to the guidance counsellors at any time. Throughout her time as a student in this School Division, she had an Individualized Education Plan (IEP) to address her learning needs. When Angel was in grade 6, in 2010, a referral was made to the school psychologist to conduct a psychoeducational assessment to gain a better understanding of her cognitive strengths and weaknesses and her current academic abilities. Angel’s strengths included nonverbal problem solving, working memory, and basic calculations skills. Overall, her level of cognitive functioning was below average. Classroom 32 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story strategies and adaptations were provided to guide Angel in her learning. The psychologist recommended that it would be beneficial for her physician to follow-up concerning Angel’s attention difficulties. An Individualized Educational Plan was developed for Angel to address her significant speech and language delays, academic delays, and her personal and emotional needs. Level II funding was applied for and approved in January 2011. This funding approval gave her part-time support in the classroom for core academic subjects. Angel’s educational information and recommendations from the school in Community #4 was provided to the CFS agency for their review. On September 30, 2010, Angel (age 12) ran away from school and was later located by Royal Canadian Mounted Police (RCMP). Deemed to be under the influence of solvents, RCMP returned her to the foster home. Upon being returned to placement, Angel expressed suicidal thoughts, and was taken to a Winnipeg-based hospital emergency room by her foster parent. While at the hospital, the mobile crisis team spoke with Angel. The mobile crisis team noted that while Angel had regular contact with her mother, this contact left Angel feeling rejected and isolated, which in turn led to her using solvents. It was noted that Angel would become emotionally distraught, suicidal, and physically aggressive while under the influence of solvents. Angel was again admitted to a crisis stabilization facility on October 1, 2010, and stayed until discharge on October 4, 2010. Angel’s foster parent attended the discharge meeting. The discharge plan documented:  Angel had a positive connection with her foster family and placement Angel was looking forward to returning to this home.  Angel’s school was very supportive of her and was expected to return immediately.  Angel’s child and family services worker was hoping to visit with Angel the following week.  Foster parents were making arrangements for Angel to meet with an art therapist on a regular basis.  There were no safety concerns present for Angel at the time of the meeting.  Mobile crisis team could be utilized on an as needed basis. Angel was discharged to her foster home on October 4, 2010. There was no evidence of any follow up by the CFS agency to Angel’s stay in the crisis stabilization facility, or to the recommendation for art therapy. Between November 5 and 6, 2010, Angel engaged in damaging property and breaking windows at her school in Community #4. 33 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Angel (age 12), was taken to a Winnipeg-based hospital emergency room by her foster parent on November 6, 2010, as Angel had been sniffing gasoline and was having suicidal thoughts. She was assessed as moderate risk of harm to herself and others, and received a child psychiatric consult. It was determined by medical officials that she was able to return home with her foster parent, and recommendations were made to follow up with community resources. Angel and her foster parent went home on November 7, 2010. There was no indication that the health system provided any follow up for Angel, and instead placed the responsibility on CFS to follow up on mental health recommendations. On November 8, 2010, Angel and her foster sister snuck out of their basement bedroom window, took their foster parent’s vehicle, drove it into a ditch, and then ran off. On November 12, 2010, Angel was taken to a hospital emergency room by her foster mother as she was deemed to be under the influence of substances. She ran away from hospital before being seen. The foster parent notified WPS that Angel had gone missing. She was later found by WPS, deemed sober, and was taken back to placement by her foster mother. The CFS file contains three handwritten notes from this time. Two notes were dated November 12, 2010, and one dated November 15, 2010. They state:  “Angel is acting up again…sniffed gas last nite…she needs to be in secured placement.”  “Angel was sniffing gas last night…it smelled like gas in the basement. RCMP would not go downstairs. Took Angel to stabilization unit but she was not admitted.”  “Angel is continuing to get out of control. Will fill out forms for 7 day lock down at Youth Addiction Stabilization Unit….” The CFS agency file documented that Angel needed to be in a secure placement and the CFS worker was going to enquire if any openings were available. The CFS agency file documentation presented for review did not indicate if such an inquiry was made by the CFS agency, and when asked by our office during the course of this investigation, the Child and Family Services Division confirmed that no referral had been received from the CFS agency (Email communication, Child and Family Services Division, June 19, 2018). The CFS agency was granted an order for apprehension and assessment under The Youth Drug Stabilization (Support for Parents) Act on November 17, 2010.3 The order specified that Angel (age 12), was to be apprehended and taken to the Youth Addiction Stabilization Unit (YASU) for assessment. It was noted that Angel had started misusing substances at an early age and was using almost daily. She had been suspended from school, was aggressive, verbally abusive, and a danger to herself when under the influence of alcohol and solvents. 3 Please see Appendix E for an information sheet regarding the Youth Drug Stabilization Act 34 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Documents on the CFS agency file dated November 18, 2010, indicated that the agency was seeking a one year Temporary Order of Guardianship for Angel. Reasons for seeking a temporary order were framed in a way that placed significant blame on Angel for predictably acting out her trauma, and included Angel’s poor school attendance, disregard for rules and authority, solvent abuse, negative coping skills, and that her mother was unable to care for her. Plans documented by the CFS agency included providing Angel with educational support to improve her academics, regular family contact, respite services, and a referral to mental health to deal with past sexual abuse and solvent abuse. Once again, there was no evidence the CFS agency implemented any of its stated plans or needed supports. File documentation noted that Angel would be discharged from YASU on November 25, 2010, and returned to her placement. The discharge meeting was attended by Angel, her foster parents, and facility staff. A summary of the recommendations from Angel’s discharge meeting included:  Residential treatment: Angel is willing to attend an out-of-province voluntary treatment centre  Contact AFM youth services to schedule an intake  Alcohol and other drugs education: Angel not willing to discuss safety in terms of self-harm but stated she would keep herself busy with other activities  View videos on alcohol and other drugs and the effects: Angel watched some educational videos about substance use and did engage in one-to-one discussions and teachings around physical effects of substance abuse  Identify triggers for use and positive strategies to deal with the triggers  Emotional/anger management: Angel is able to vocalize her feelings around past abuse and has stated that she did not feel protected  Safety planning surrounding self-harm: Angel will be walked to school by one of her foster parents, or she will walk alone. If at any point she leaves the school property, RCMP will be called to pick her up  Explore living arrangements: Angel will be returning to live with her foster parents, with the expectations for Angel to include communicating her feelings, attend all family meals, and complete some household chores. Angel expressed that she would like to return to Community #1 to live with her mother  Develop treatment plan Discharge information indicated that forms would be completed for Angel to attend addictions treatment at the out-of-province voluntary treatment centre. On December 4, 2010, case notes in the foster care file documented, that “Angel will be going for treatment in January 2011.” Ultimately, this plan was not pursued because Angel changed her mind and did not agree to attend this out-of-province voluntary treatment facility (Email communication, CFS agency, May 5, 2018). 35 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Prior to returning Angel to the foster home, there was no evidence that the CFS agency completed of any of the assessments that were required according to minimum provincial case standards. Monthly foster home contact sheets were placed on the CFS agency file for several months in 2011, from January to June. These reports noted that Angel consistently spoke with her mother and grandmother twice a week and that she missed her family. Angel’s behaviour was described as delightful, funny, and fun to be around. Setting clear boundaries for Angel was identified as a need. She had to be reminded several times a day regarding using “appropriate conversation.” The foster parents felt that Angel “has come many miles in her behaviours and [foster parents] look forward to seeing her develop into a smart, healthy young lady.” Education updates recorded on the monthly foster home report, documented that Angel did good work when she was focused, but that there were still disruptions in the classroom. Angel completed a drug awareness education program, participated in a spring school concert, participated in track and field day, and went on two field trips with her class. The foster parents documented that they would be taking Angel to West Edmonton Mall for spring break if her behaviour was good and weather permitting. It was recorded that Angel was doing well with swimming lessons and that she was registered for cheerleading starting in May 2001. There were two incidents documented of Angel sniffing solvents: on March 24, 2011, and April 25, 2011, and each of these incidents also involved concerning behaviour in the community. The CFS agency amended case plan, dated April 1, 2011, documented that: “Angel needs to have mental health counselling to help her cope with her abuse and the grief she carries on the friends & family she has lost. Worker needs to make referral to [mental health support] who services [Community #4] area.” Once again, no evidence of follow through on this need for mental health treatment was located on the CFS file that was presented by the CFS agency for review during this investigation. On May 25, 2011, Angel and her foster sister snuck into a house through a basement window, and stole alcohol from the refrigerator in the basement. Angel and her foster sister were seen by a resident of the house, who was home at the time the girls snuck in. In an email dated, May 26, 2011, the CFS agency received an intake from the designated intake agency, concerning a complaint by a community member regarding the foster home where Angel was placed. The concerns expressed included, the youth being out past midnight, no supervision, break and enters, setting fires, and sniffing gasoline. The source of referral stated that they were concerned for the youth living in the foster home and for other children in the community. A supervisor from the CFS agency spoke to the foster parent, who agreed that the girls “were getting into trouble,” but they felt the information that was shared was false. A meeting was scheduled with the youth living in the foster home, their assigned CFS workers, and the foster parents. The meeting was to take place May 31, 2011, 36 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story and additional information was to be gathered through individual interviews with the youth. The CFS agency file contains no information on whether this meeting actually occurred. Angel celebrated her thirteenth birthday on June 27, 2011. The foster care monthly contact report form documented that Angel had a birthday party at the foster home and went swimming in the evening. Angel’s grade 6 report card issued on June 30, 2011, included comments from one of her teachers: I enjoyed teaching Angel this year. I was happy to see her come to this school and make friends and adjust well to a new learning environment! I appreciated her kind personality when I was able to catch glimpses of it! I hope that she has a safe and wonderful summer and good luck next year in grade 7. The July 2011 foster care monthly contact report form, documented that Angel had no major incidents for the month of July. Highlights documented included that Angel had attended a Brittany Spears concert, had gone bowling, swimming, attended a rural community festival, waterslides, and mini golfing. The plan was for Angel to attend summer camp from August 15-20, 2011. Angel flew to Community #1 from August 5-12, 2011 to visit her family. She stayed with her maternal grandparents. There was no safety plan documented on file to ensure Angel’s safety while in Community #1. Angel was in grade 7 for the 2011-2012 school year. Her Individualized Education Plan was reviewed on November 7, 2011, to make plans for the school year. Angel’s education support team was comprised of the principal, resource teacher, classroom teacher, foster parents, CFS agency worker, and school social worker. There was no indication this team included Angel as part of the planning meetings. The goals identified at this meeting focused on the areas of:  Academic,  Responsibility/Independence/Citizenship,  Self-management, and  Social well-being. An individual adaptation plan was implemented for Angel. These are supports provided to students to assist them with the learning process. Angel continued to receive support from an educational assistant through the level 2 funding approval. Angel’s educational information from her school in Community #4 was provided to the CFS agency. 37 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Angel flew to Community #1 from December 21, 2011 – January 4, 2012, to spend the holidays with her family. She stayed with her maternal grandparents. There was no safety plan documented on file to ensure Angel’s safety while in Community #1. Addictions Foundation of Manitoba (AFM) conducted an assessment of Angel’s (age 13), use of substances on January 23, and February 6, 2012. The AFM assessment process included counsellor interviewing, client self-reporting, and the administration of a screening tool (identified as the Drug Use Screening Inventory [revised], or DUSI-R). Angel and her foster parent were interviewed as part of this process. The results indicated that Angel’s level of involvement with substances was transitional abstinence, meaning, she was trying very hard and had been successful remaining abstinent. Angel was offered an opportunity to participate in group programming at AFM, but she declined, as she said she could remain abstinent on her own. It was also recorded that mental health counselling might benefit Angel. The AFM assessment outcome was not shared with Angel’s legal guardian, the CFS agency; the AFM assessment is not located on the CFS agency files. Documentation completed by the CFS agency in preparation for court and dated February 23, 2012, noted that Angel was attending school and getting educational assistant support. She was described as having a positive attitude in school and towards her foster parents. All of Angel’s siblings were in care at this time due to safety and protection concerns related to Angel’s mother’s chronic addictions. The CFS agency documentation recorded that Angel was upset with her mother for not attending treatment or demonstrating a desire to change. It was further noted that a psychological assessment had been completed, indicating that Angel had academic delays, attention deficit hyperactivity disorder (ADHD), and fetal alcohol spectrum disorder (FASD). There was no FASD assessment presented on file for review confirming Angel’s FASD diagnosis, and the psychological assessment noted to have been completed, was also not found on files presented for review.4 A one-year Temporary Order of Guardianship was granted by the courts to the CFS agency on February 23, 2012. The March 2012 monthly foster home contact sheet reported that there were no legal incidents with Angel this month. It was also reported that Angel completed an AFM assessment. The foster parent also indicated that Angel had attended a youth clinic “a few times” and had learned “some sexual education.” Highlights for the month, included: Angel has been in pleasant spirits for most of the month, she has been calling her mom regularly on Wednesdays and this seems to [be] a highlight for her. Angel completed and passed her swimming lessons and now will be going to Swim Kids 6, she is also enrolled with [a local soccer team] for the soccer league starting the end of April. 4 There were two psychological assessments conducted by the school psychologist. CFS agency documentation did not indicate if this assessment was referring to one of those educational assessments or an alternate assessment. 38 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Angel flew home to Community #1 from March 26, 2012 – April 2, 2012, to visit her family. Once again, the CFS agency did not document a plan to ensure Angel’s safety while in Community #1. A case plan on file dated April 1, 2012, noted improvements in Angel’s behaviour; however, she continued to struggle with rules, expectations, and consequences at school and at home. It was noted that while her coping skills were improving, Angel continued to use cannabis on a number of occasions. Angel was noted to continue to struggle with being away from family which impacted her behaviour. The goals the CFS agency identified for Angel included, establishing a healthier relationship with her mother, regular contact with siblings, and working with a school counsellor to help her understand the negative impact of alcohol and drug use. The CFS agency files did not describe any further action the agency took to address Angel’s needs. On April 30, 2012, Angel was reported missing to RCMP. The CFS agency file documentation did not record who filed the missing person report. RCMP notified WPS to search an address in Winnipeg where it was believed Angel may been. Angel was successfully located and returned to her foster home in Community #4. Angel flew home to Community #1 from August 3, 2012 – August 17, 2012, to visit her family. There was no safety plan documented on file to ensure Angel’s safety while in Community #1. There was no information on the CFS file that indicated the agency took any interest in knowing what happened for Angel when she attended these visits home. The CFS agency did not document where she stayed while in community, whom she would visit while there, what concerns the agency might have, or what measures would be put in place to protect Angel, which would have been vitally important given the previous sexual assaults, solvent abuse, and other safety risks Angel had experienced during previous visits home. Angel attended grade 8 at the same middle school in Community #4 for the 2012-2013 school year. Her Individualized Education Plan (IEP) was updated and level 2 funding continued for the school year. The domains focused on were in the following areas: academics, responsibility, self-management, and social well-being. The participants included the principal, resource teacher, classroom teacher, foster parents, CFS agency worker, and school social worker; there is no indication Angel was included in these meetings. The team identified an adaptation plan to better support her learning needs. The education files reviewed during this investigation did not document if Angel was present for the IEP update meeting where goals were established. Angel’s educational information from the middle school in Community #4 was provided to the CFS agency for their review. Comments on Angel’s report card at the end of the school year included: “enthusiastic and pleasant student,” “Angel worked well on the topics she was interested in,” and “good course performance.” 39 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story On October 10, 2012, Angel (age 14) was picked up by RCMP for being intoxicated and was being held in RCMP cells. A decision was made to transport her to a Winnipeg-based hospital for a mental health assessment, as she had been expressing suicidal thoughts for a number of days in a row. Medical personnel noted that Angel had self-harmed and written a suicide note that day. The content of the suicide note was not documented in the medical records, which were reviewed during this investigation. It was noted that she had been intoxicated and expressing suicidal thoughts while in RCMP cells. Angel was noted to have gone for a visit in Community #1 in August, and had been having a difficult time since returning. At the children’s emergency room, she was assessed as low risk of harm to herself or others, and was sent home with her foster parent. The discharge instructions noted to contact the “community health worker.” The CFS agency received an intake on October 11, 2012 regarding the October 10, 2012 incident. Follow up was assigned 18 days later on October 29, 2012 to a CFS agency worker in Winnipeg. The safety plan documented by the CFS agency included the information that:  Foster parent is very familiar with Angel  Foster parent is monitoring child  Foster parent and Angel will communicate to one another A review of the plan by the CFS agency supervisor included the additional comments that:  Worker will continue to support foster child in home  Child will attend her mental health counselling There was no mention in the safety plan of the ongoing issues of solvent abuse, unaddressed sexual abuse, possible sexual exploitation, self-harming behaviours, or multiple suicide attempts. There was no evidence that the CFS agency followed up on providing any mental health or other support services for Angel. Angel (age 14), flew to Community #1 from December 19, 2012 – January 7, 2013 to visit her family for the holidays. It was documented that Angel would be staying with her mother who was then living at a local crisis centre, and with her maternal grandmother. There was no safety plan documented on file to ensure Angel’s protection while in Community #1. On January 6, 2013, the CFS agency staff received a telephone message from an anonymous caller that Angel told her grandmother that she was “raped” and Angel was scared to tell anyone what had happened. RCMP were notified immediately. During her interview at the CFS agency office in Community #1, Angel relayed that on December 31, 2012, she had been sexually assaulted by an adult male in the community. This was Angel’s third known sexual assault. 40 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Angel refused medical intervention while in Community #1. She returned to the foster home in Community #4 on January 14, 2013 and her foster parent took her to be seen by a physician located close to the foster home. The CFS agency investigation form on file documented the agency’s following actions:  Angel is receiving supports from foster home and respite providers  Safety plan in place with Angel checking in with foster parent and school counsellor will be made aware of the assault, so school support can be provided to Angel.  Victim services involvement  Medical services provided in [community name]. The alleged offender was charged with sexual assault and sexual interference. Victim Support Services sent out an initial letter on March 7, 2013, offering support to Angel. Numerous attempts were made by victim support services to contact Angel’s CFS agency worker to set up a meeting between Angel, a victim support services worker, and the crown attorney. Eventually, through victim support services, Angel met with the crown attorney prior to the trial date to prepare Angel for testifying, which would eventually occur in May 2015. On April 28, 2014, Angel was given a tour of the court room, discussed the court process, and Angel confirmed that she wanted the victim support services worker to sit next to her while she testified. Angel then met with the crown attorney and reviewed her statement. The safety assessment completed in early 2013 by the CFS agency deemed Angel safe, as Angel had returned to her foster home in Community #4, and support would be provided by the foster parent and school counsellor. Despite its requirement to do so, the CFS agency did not refer this matter to the child abuse committee for investigation and follow up. Finally, more than a year later, in May 2014, the CFS agency unit in Community #1 sent the January 2013 intake form to the CFS agency child abuse coordinator for review, and the child abuse coordinator forwarded the information to the child abuse committee in June 2014. After two adjournments, the criminal trial for the sexual assault on Angel was finally set for May 14, 2015, in Thompson. Angel was flown in with a support person for the proceedings and testified in court. The outcome of the trial was an acquittal. Throughout the two years that the victim support services worker was connected with Angel and her supports, conversations were documented in the victim support services records regarding providing mental health counselling to Angel. On October 23, 2013, the foster parent told the victim support services worker, that she would make all the arrangements for Angel’s therapy, and that she had set up 41 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story sessions with a counsellor. On October 24, 2013, the victim support services worker raised the topic of counselling with the foster parent. The foster parent explained that the cost would be covered by provincial health care or by the CFS agency. The foster parent also stated that Angel would be meeting with a psychiatrist in the near future for an evaluation. In a conversation dated December 3, 2014, between the victim support services worker and the CFS agency worker, the CFS worker apparently advised victim support services that Angel already had monthly sessions with a mental health therapist, and the CFS agency planned to increase the frequency of those visits after the criminal trial concluded. There is no evidence on the CFS file that mental health supports were requested by CFS or provided to Angel. At the close of the trial in May 2015, Angel’s victim support services worker called the foster parent to inform her of the acquittal outcome, that Angel was on her way back to Winnipeg, and that she did not know of the acquittal yet. The foster parent indicated Angel would receive proper supports. Shortly after Angel had disclosed being sexually assaulted while on a visit home, a letter was sent from Angel’s school resource teacher to the CFS agency, dated February 26, 2013. The letter raised serious concerns where – not for the first time – concerns were being expressed about the foster home where Angel was placed and provided information that conflicted with some of the ways the foster home was describing their abilities to intervene and support Angel while she was living in their home. In their letter, the school expressed numerous concerns regarding Angel. These concerns included the extent to which Angel was consuming alcohol and other drugs, ease of access to substances, extreme mood swings, and suicide attempts. It was also reported by the school that Angel had been seen frequently unsupervised, after school hours, observed to be walking to a nearby town where she liked to hang out. The letter further stated that Angel admitted to obtaining drugs in the nearby town, which were supplied by the boyfriend of her foster sister who lived in that town. There were other complaints noted regarding the foster home where Angel was placed, including that “[Angel] does not want to go home,” a lack of proper supervision, and a lack of safety for Angel’s personal belongings in the foster home. There was no indication that the CFS agency responded in any way to the concerns expressed by Angel’s school. A case plan on the CFS agency file dated April 1, 2013, continued to note Angel’s struggles with impulsivity, anger, and substance misuse. The case plan noted that in addition to being sexually assaulted in Community #1 in December 2012, Angel had disclosed that she had also been sexually 42 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story assaulted in Winnipeg by an unknown male who had picked her up in a vehicle. The CFS file did not document to whom Angel had made this additional disclosure of a sexual assault. The CFS file noted the additional sexual assault could not be followed up on by police as Angel did not disclose the assault until long after the incident occurred, and she was unable to provide a sufficient description of the alleged offender. However, during the investigation by our office, we did review a letter Angel had written to her mother, which describes that she was sexually exploited by an unnamed male adult and details the horrific sexual assault she survived. The letter was both a detailed disclosure and an apology to her mother, demonstrating that Angel did not understand that what happened to her was illegal, horrific, and a calculated assault by an adult predator. There was no entry on the CFS agency file stating whether Angel’s mother ever received this letter. There was also no documentation as to how the CFS agency came to be in possession of this letter, that they understood it to be a disclosure of a youth who was being sexually exploited, regarding what the CFS agency did in response to the disclosure, or even how the CFS agency would assess her risk and safety plan to protect Angel in the community. An excerpt of this letter, in Angel’s own handwriting, is included on this page and on the next. Graphic content has been redacted. [2.5 pages redacted] …continued on the next page… 43 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story [1 page redacted] [Additional details redacted] 44 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The April 1, 2013, CFS case plan spoke of Angel’s relationship with her mother, and specifically that, “Angel has a lot of anger towards her mother because of her chaotic upbringing and being in and out of care for most of her life.” The case plan goals were for Angel to:  Remain in her current placement,  Receive counselling from victim support services,  Become involved in extra-curricular activities,  Begin to address the issues she had with her mother,  Attend quarterly family visits, and  Attend counselling from a therapist to address family of origin issues. CFS file documentation did not indicate which services, if any, were provided to Angel. On May 17, 2013, Angel was removed from her placement and placed in a shelter in Winnipeg for getting into a physical fight with her foster sibling. Angel returned to the foster home in Community #4, on June 3, 2013, where the foster sibling whom she had physically fought still resided. File recordings did not indicate that a safety plan was created, prior to Angel returning to the foster home, however the October 1, 2013, case plan stated that the foster parents were keeping a close eye on the situation, and were attempting to resolve the issue between the two girls. The case notes on the CFS agency foster care file, dated June 4, 2013, documented that concerns were again raised by a community member about the foster home in which the agency had placed Angel. At this time, a CFS agency worker received information from a community source that the foster home in Community #4 was “mistreating” the foster children in the home. Concerns listed included: forcing the youth to stay in the basement and not purchasing needed clothing for Angel. The source of referral stated that Angel disclosed to the source of referral that Angel was being sexually exploited in exchange for drugs, and that Angel’s foster parent was aware of this information. CFS documentation indicated that the CFS worker informed the supervisor and the plan was that supervisor would follow up. There is no evidence the CFS agency worker or supervisor followed up regarding the concerns related to the foster home, or on the additional reports that Angel was being sexually assaulted in the community. On June 4, 2013, the CFS agency worker signed a CFS declaration of support for Angel to receive federally-funded crisis intervention and mental health therapy. The CFS agency case notes stated the referral for counselling was faxed to the federally-funded clinical therapist. There is no evidence on the CFS file that therapy was provided to Angel. 45 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The CFS agency worker and Angel’s foster parent met school representatives on June 7, 2013, to address ongoing concerns from the school, communication with the CFS agency, and to plan for successful programming for Angel. The July 2013 monthly foster parent contact sheet, stated that Angel was doing well at home. She had attended summer camp, and was starting Grade 9 in September 2013. It was also documented that the CFS agency worker and supervisor visited the foster home in March 2013. On September 25, 2013, the community mental health office close to Community #4 received a referral for Angel from her family physician, due to Angel having suicidal thoughts. Further information was required from the CFS agency, and a follow up phone call was made to the CFS agency. The mental health referral information was shared with a worker for the CFS agency. The CFS agency worker was not aware of the referral, stated they would speak to the foster parent regarding the referral, and would call back if they wanted to pursue this mental health service for Angel. No further contact was made between the community mental health program and the CFS agency. In September 2013, Angel started her grade nine year in the school in Community #4. On January 24, 2014, a reassessment of Angel’s cognitive and academic skills was conducted, in order to provide Angel with appropriate programming as she transitioned to high school. The school psychologist conducted the reassessment. Concluding recommendations included that:  It would be beneficial to follow-up Angel’s concerning social-emotional, attention and behavioural difficulties with a mental health professional.  Angel would benefit from having a behaviour intervention plan at school that includes some strategies to help motivate her and manage any problematic behaviour.  Angel has cognitive weaknesses which may be affecting her ability to perform in school. Important adaptations for Angel include verbal reasoning, working memory, processing speed, and attention and executive functioning. An updated case plan dated October 1, 2013, noted that Angel’s most recent family visit in Community #1, in July 2013, “did not go well” and Angel had started sniffing solvents again. When she returned to the foster home after the visit home, Angel was caught sniffing solvents in the foster home. The case plan noted that the CFS agency would be applying for another one-year temporary order of guardianship, and the CFS agency would “begin age of majority planning during this time as it does not look like Angel can return to the care of her mother and she needs to receive the continued support in her foster placement.” 46 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Documents dated October 24, 2013, indicated that the CFS agency had decided to seek a permanent order of guardianship for Angel. Their stated reasons included the transient lifestyle of Angel’s mother who had not sustained any positive changes in her life, Angel’s substance misuse, and an order for the CFS agency to begin permanency planning for Angel. Angel was sent home from school on November 25, 2013, due to being ill from consuming alcohol the previous night. A teacher from Angel’s school contacted the CFS agency worker and faxed a letter to the CFS agency that same day expressing concern for Angel. The letter noted Angel had become increasingly difficult to manage in school as she was non-cooperative, would leave class without permission, and was noted to be rude and aggressive. Concerns were also described regarding Angel’s drug and alcohol use, and possible sexual exploitation. Angel had disclosed to school staff that she frequently went to a particular home in a town close to Community #4 where she consumed alcohol and drugs. Angel also disclosed to the school that a male tried to “initiate sex with her” but she was able to get away from him. The school indicated that they were very worried for Angel’s safety. The teacher requested a meeting with the CFS agency worker for November 27, 2013. There was no response from the CFS agency to the school. While there is no evidence the CFS agency attended any meeting with the school in response to the school’s reported concerns, our office did locate a handwritten response on the education files reviewed during this investigation that stated: “Response: change of social workers November 27, then no further response.” Even though additional concerns regarding Angel being sexually exploited were brought forward to the CFS agency, further assessment and planning that should have been completed by the agency - and which is required within a mandated provincial CFS agency - was again not initiated by the agency. On December 18, 2013, Angel (age 15) was made a permanent ward of the CFS agency. A case note dated January 6, 2014, indicated that the CFS agency received a phone call from Angel’s mother. Angel had called her mother crying, and told her mother that she was lonely. Angel’s mother requested a visit. There was no further documentation on the CFS file that any action occurred in response to this request from Angel’s mother or to the information that Angel was in distress. Angel’s school in Community #4 faxed a report on January 15, 2014, documenting concerning incidents that occurred with Angel. On January 13, 2014, Angel arrived at school after lunch and informed the educational assistant that she and her foster sisters had sniffed a considerable amount of solvents and consumed high levels of alcohol on the weekend. She expressed suicidal thoughts, and she was described by the school personnel and being very “weepy.” The following 47 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story day, Angel did not attend school and when the foster parent was called, she indicated that Angel and she had a “heated argument” and that Angel had left the home. The foster parent called the RCMP to report Angel missing. The RCMP subsequently found Angel at her school in the washroom, “weepy” and “distraught.” RCMP spoke to Angel, and for Angel’s safety, deemed it necessary to take her to a Winnipeg-based hospital for a mental health assessment. Angel’s foster parent was notified. At the end of this report, the school asked the CFS agency to provide them with information to best plan for Angel. The school noted that they were concerned about keeping Angel safe, and requested a representative from the CFS agency attend a meeting at the school, if Angel was to return to the foster home. There was no evidence on the education files reviewed during this investigation that the CFS agency responded to this report or request. After the RCMP transported Angel to hospital, the emergency room documentation form noted that Angel had been sexually assaulted in the past, she denied having a suicide plan, but stated that she did not feel safe. Further details of why Angel did not feel safe, were not recorded in the medical records. It was noted that she was seeing a counsellor in Winnipeg. The mobile crisis team came to the emergency room to assess whether Angel required a stay at a crisis stabilization facility. Angel was admitted to the crisis stabilization facility. The facility notes from her stay there indicated that Angel and her foster mother had been “fighting” a lot and Angel wanted to leave her foster home and find a new placement. Angel was discharged from the stabilization facility on January 17, 2014 and was moved by the CFS agency to a new foster placement in another new community, Community #5. Angel lived there for only one month. Angel was reported missing to WPS on February 5, 2014. The CFS agency file does not document who reported her missing. WPS officers located Angel at a downtown hotel. She was returned to her foster placement in Community #5. Documentation does not provide further information on a response by the CFS agency, or if they recognized this as a sign of her ongoing sexual exploitation. On February 19, 2014, Angel’s foster parent called the CFS agency. The foster parent stated that Angel and her foster sister were “out of control,” verbally abusing the foster parent, throwing “their stuff around,” and “packing their belongings.” Two CFS agency staff went to the foster home to talk to Angel and her foster sister. Angel and her foster sister said they did not want to live at the foster placement any longer. After they calmed down, the CFS workers left, and then Angel and her foster sister also left the placement shortly afterwards. RCMP were called by the foster parent. The RCMP told the foster parent that WPS needed to be notified and that the RCMP would forward the missing persons information to WPS for response. 48 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The designated CFS intake agency in Winnipeg was contacted on February 19, 2014, by the same downtown hotel where Angel had been located earlier that month. The hotel staff requested that CFS come and pick up Angel and the other youth who were loitering in the hotel lobby. WPS was dispatched to the hotel, located Angel and her foster sister, and then contacted Angel’s foster parent. The foster parent confirmed that the two youth could not be returned to her home. Angel and the other youth were transported to a youth shelter. Angel was placed by the CFS agency in a different foster home in Winnipeg, on February 24, 2014. Angel’s case plan dated February 24, 2014, blamed Angel for the circumstances of her life and reflected no understanding by the CFS agency of the impact that early, ongoing, and sustained trauma was having in Angel’s life. The CFS agency documented that: Presently Angel is still an out of control teenager who throws tantrums if situations don’t go her way, she will also lash out at people who try to reach out to help her. Her previous placement with [name removed] has broken down due to Angel assaulting foster sibling. Angel is now reported to be running away from placements and currently not attending school. Angel still continues to get into drugs/alcohol. These types of behaviours stem from her mother abusing alcohol [during] her pregnancy, which is now affecting her daily challenges. Angel’s needs as indicated in the CFS agency case plan included placement in a facility where she could receive around the clock supervision, counselling, education regarding her risk-taking behaviours, and that she needed to attend both school and court hearings. File documentation does not indicate which supports were put in place for Angel by the CFS agency. A subsequent case plan dated February 27, 2014, documented that: Angel needs to be placed in a proper facility where she can get 24/7 supervision. But also to be taught about life skills and appropriate self conducts to others. She will need on-going counselling therapy sessions. Once again, there is no documentation that “on-going counselling therapy” was ever provided to Angel. One of The CFS agency’ goals documented for Angel was “to place Angel in a stable home or a facility that will meet her daily needs of constant 24/7 supervision.” There was no further documentation on file, identifying the step The CFS agency would take to meet Angel’s constant supervision needs. On March 4, 2014, Angel was found by an apartment security guard in downtown Winnipeg, crying, intoxicated, and unable to remember her placement address. WPS was called, who contacted the Winnipeg designated CFS intake agency to get further information about Angel. WPS took Angel to YASU 49 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story for the night. In response to this event, Angel was charged with underage consumption of liquor. The crisis facility staff was to notify the CFS agency worker the following day. CFS file recordings did not indicate further follow up regarding this incident. Angel and another child in care attended the Winnipeg designated CFS intake agency in the early morning of April 15, 2014, requesting a ride back to their placement, however, Angel’s foster parent refused to allow Angel to return. Angel was taken to the CFS agency office in the morning. She was placed in a shelter on April 18, 2014, and four days later, she was relocated to another shelter, which she remained at until May 8, 2014. This was Angel’s 46th different placement to date. The CFS agency received incident reports from the shelter that Angel had been absent on four different occasions. The shelter filed a missing person report for each incident. For one of the incidents in early May, the shelter documented that Angel had returned to her placement smelling of alcohol and staggering; Angel refused medical attention during this incident. Shelter staff conducted 15-minute room checks on Angel for her safety throughout the night. Each incident was reported to Angel’s CFS worker. On May 8, 2014, Angel was placed back with her previous foster home in Community #4. Angel and another foster child were reported missing from the foster home on June 21, 2014. RCMP located Angel under the influence of alcohol and passed out. She was kept in police custody until she was deemed sober and then returned to her placement. There was no documentation on the CFS agency file that any follow up by the agency occurred. On October 16, 2014, the CFS agency worker signed a CFS declaration of support for Angel to receive federally-funded crisis intervention and mental health therapy. The monthly foster parent report for November 2014, spoke of Angel’s frequent absences from placement and her ongoing substance misuse. On the evening of December 29, 2014, Angel (age 16), and two other foster youth were hit by a vehicle while walking along the highway. File documentation documented that Angel and two other youth had left the foster home at 4:20 p.m., despite being told that they did not have permission to leave the home, and that it was very cold outside. Angel had spoken to her mother earlier that day, who was presently in Winnipeg. Angel and the two other youth were walking on the highway, heading to Winnipeg, when at approximately 8:00 p.m. they were struck by a vehicle. The driver did not see the youth until they were hit and the area was described as dark and not well-lit. Angel was transported by ambulance to a hospital emergency room, while one of the other youth was airlifted to hospital, and the third youth was taken to hospital in a neighbouring community. Angel had sustained a number of cuts to her body, a broken right leg, a broken left foot, and a broken ankle. Angel required surgery to repair to 50 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story her leg and foot. She was released from hospital on January 7, 2015. Alcohol or solvents were not considered factors for any of the individuals involved in the accident. The designated CFS intake agency for the area received a referral from RCMP on February 7, 2015. Angel (age 16), had been reported missing by her foster parent, and RCMP had located Angel and another foster child at a residence, intoxicated. RCMP reported to CFS that they had found Angel lying on a bed with an older, adult male lying on top of her. The RCMP described what they witnessed as Angel “almost being sexually assaulted,” instead of assessing that this child was intoxicated, unable to consent, and was most certainly being sexually assaulted by the adult male who was on top of her. In response to the incident, RCMP detained both girls in police custody until they were deemed sober, and then the RCMP charged Angel and the other youth with underage alcohol consumption. RCMP advised the designated CFS intake agency of their belief that the foster parent did not have the ability to protect the youth living with her. The designated CFS intake agency forwarded this information to Angel’s CFS agency without taking further steps as they should have to gather information for the required child abuse investigation. There was no documentation on the CFS agency files that a child abuse investigation was conducted, nor did Angel’s CFS agency take any steps to protect Angel as a youth who was being repeatedly sexually exploited. There was also no documentation in the CFS foster care file, that the RCMP’s concerns regarding the foster parent were addressed by the CFS agency in any way. Further discussion of this incident with the RCMP, took place on October 5, 2018. RCMP did not have information on this specific incident in their database, as our office was informed that older RCMP records get purged from their database. RCMP could not comment on their response, and the officer who made the referral to the designated CFS intake agency no longer works for the RCMP. On February 27, 2015, the foster parent reported to the RCMP that Angel and another foster child were missing again. Both girls were located by RCMP and deemed intoxicated. They were kept in custody until sober and then charged under the provincial liquor laws for under-age consumption of alcohol. The February 2015, foster home report indicated that Angel had several incidents that required the police being called due to unapproved absences and alcohol misuse. The foster parent requested a meeting with Angel’s CFS agency worker to discuss these concerns. CFS agency file recordings did not document if this meeting occurred. 51 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story On March 4, 2015, the CFS agency received a report that a disclosure had been made by a youth residing in the foster home in which Angel was living. Allegations were that the foster father had sexually assaulted another child in the home. RCMP were notified and interviewed the youth in the home; Angel made no disclosure and indicated she felt safe. The CFS agency worker met with Angel on March 5, 2013; Angel reiterated that she felt safe and wanted to stay in the home. A safety plan was created with Angel. The safety plan included that:  The foster father would leave the placement until the conclusion of the investigation.  The foster father was not to have contact with any child in care placed in the home until further notice.  A CFS agency support worker would stay in the home for the night to provide supervision.  Support workers which had been independently hired by the foster parent would continue their duties. In addition to the safety plan, a safety contract was signed by the foster parent and the CFS agency. On March 18, 2015, the CFS agency concluded their investigation as Unsubstantiated – Did not occur. The alleged victim chose not to remain in the home and was placed elsewhere by the CFS agency. The following recommendations were made as a result of the investigation:  The workers for the children remaining in this foster home maintain contact with the girls and create a positive and communicative relationship with the foster parents.  The workers for the remaining children, develop positive relationships with the schools that the children attend, to ensure that educational matters can be addressed by the agency in a timely and positive manner.  The foster care department speak with the house regarding the calls to RCMP and develop a strategy to help foster a more supportive relationship between the foster home and the RCMP detachment. For the March 24-April 4 spring break from school, Angel had requested a visit home, which had not been approved by the CFS agency due to a significant event that had occurred in her home community. The CFS agency had determined they were uncertain if Angel would be safe if she returned home at that time and did not approve her request. Towards the end of March 2015, Angel returned to her foster home intoxicated. She indicated to her foster mother that she had consumed alcohol to get back at the CFS agency for not allowing her to go home. This information was documented in the March 2015 monthly foster home report. 52 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story In April 2015, a relative of Angel’s died in her home community (Community #1). As the CFS agency remained concerned for Angel’s safety in her home community, they again did not approve her travel to Community #1. Instead, Angel did attend the wake, which was held in Winnipeg. On June 3, 2015, Angel was picked up by RCMP, intoxicated, after having snuck into an apartment block. The May 2015 monthly foster parent report noted that there was a need for more therapy for Angel concerning being a victim of sexual assault. An appointment was scheduled with the Addictions Foundation of Manitoba (AFM), and also with a mental health counsellor that the CFS agency contracted. The July 2015 monthly foster parent report spoke of Angel staying out late, consuming alcohol, and misusing Gravol®. Angel’s case plan dated July 17, 2015, spoke of Angel’s continued alcohol and drug misuse and noted that she was receiving counselling twice a month. CFS case notes indicated that Angel had been missing on August 15, 2015, and was found intoxicated. On August 26, 2015, the First Nations of Northern Manitoba Child and Family Services Authority (“Northern Authority”) received a complaint from RCMP regarding concerns with the foster home in Community #4, which was licensed by Angel’s CFS agency and which was where Angel resided. In an email sent to the CFS agency the Northern Authority on August 26, 2015, the RCMP had reported to the Northern Authority, that the RCMP was attending the foster home on a daily basis due to the foster children’s behaviours. The RCMP had further reported that they felt there were too many children in the home, the children are not getting the resources they need, and that the CFS agency “does nothing” to assist the RCMP. The Northern Authority directed the CFS agency to investigate the concerns. Each of the relevant CFS agency supervisors were advised to draft a report for each of the children then living at the foster home, outlining the supports in place at the foster home, and any successes and changes observed in the children. The CFS agency foster care department was advised to provide a report on their involvement with the foster parents, and the ability of the foster parents to manage the youth in the home. Despite the ongoing and repeated concerns about the placement being brought to the attention of the CFS agency from multiple community sources, the CFS agency indicated their support for the foster parent. An email dated September 1, 2015, of a discussion between the CFS agency staff, indicated that there were, ”…absolutely no issues with this foster parent, she is a great placement for high risk and vulnerable youth.” The CFS agency noted the foster parent was very respectful and understanding, and treated the youth they fostered, “as one of their own children.” It was also noted that the youth living there described the foster parent, “…as being a mother to them who understood their wants and needs.” 53 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story APPREHENSION 14 (AUGUST 5, 2010) Placement #32 Winnipeg Placement #33 Winnipeg Placement #34 Winnipeg Placement #35 Winnipeg Placement #36 Community #4 Placement #37 Winnipeg Placement #38 Community #4 1 YEAR TEMPORARY ORDER (December 23, 2010) PETITION FILED FOR FURTHER ORDER (December 23, 2011) 1 YEAR TEMPORARY ORDER (February 23, 2012) PETITION FILED FOR FURTHER ORDER (February 23, 2013) PERMANENT ORDER OF GUARDIANSHIP GRANTED (December 8, 2013) January 14, 2014 Placement #39 Winnipeg January 17, 2014 Placement #40 Community #5 February 19, 2014 Placement #41 Winnipeg February 24, 2014 Placement #42 Winnipeg February 27, 2014 Placement #43 Winnipeg April 18, 2014 Placement #44 Winnipeg April 22, 2014 Placement #45 Winnipeg May 8, 2014 Placement #46 Community #4 August 5, 2010 August 16, 2010 August 23, 2010 August 27, 2010 August 27, 2010 May 18, 2013 June 3, 2013 On an early fall afternoon in 2015, Angel and her foster sister walked to a nearby community. They met up with a friend at a local restaurant, who was with another male “X”, who the girls just met that day. The four of them walked around the streets of the community, when male “X” removed a pill bottle from his pocket. Both Angel and her foster sister took a pill each and the four of them continued to walk around. Angel ingested more pills from male “X”. The four ended up at the local drop-in centre, where they stopped to play some video games. Angel’s foster sister started feeling ill and she saw that Angel was behaving “very drunk.” According to the foster sister, Angel was “stumbling and slurring.” Angel’s foster sister called their foster mother at approximately 8:00 p.m., stating that she was not feeling well and needed a ride home. When she was picked up, Angel was not with her; this was the last time that the foster sister saw Angel. At approximately 8:45 p.m., Angel, a friend, and male “X” left the drop-in centre. They helped Angel walk to the home of male “X”. Angel’s friend snuck Angel into the home through a window so she could sleep (RCMP statement summaries). Angel was drowsy and stated that she wanted to sleep. In the morning, male “X” tried to wake Angel up but was unable to. He threw water on her face, but was still unable to wake Angel, so he called 9-1-1. Angel was pronounced deceased that morning. 54 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Later that day, a director from Angel’s CFS agency received a telephone call from RCMP confirming Angel’s death. The CFS agency contacted an Elder from Community #1, who then notified the Chief and Council and Angel’s maternal grandmother of her death. The CFS agency staff also contacted several of Angel’s family members. The Report of Medical Examiner listed Angel’s immediate cause of death to have been acute opiate toxicity (oxycodone). The qualitative volatile screen detected 865 ng/ml of oxycodone. The manner of death was deemed accidental. A child abuse investigation was initiated by the CFS agency child abuse coordinator in the fall of 2015. The file remains open. CFS agency staff members attended the foster home in Community #4, to provide support to the foster family and the other children living in the home. The school was notified of Angel’s death, by the foster parent, and they offered school counselling services to the students. The foster parents requested to have a memorial in Community #4 before Angel went home to Community #1. The CFS agency supported this ceremony, and arrangements were made for former foster children who were close to Angel, to travel to Community #4, and attend the memorial. The school provided the space to have lunch afterwards. Angel’s funeral was held in the north, in her home community. Angel’s mother called Angel’s foster parents and invited them to attend the funeral in the community, which they did. CFS agency staff attended both funerals to provide support to family and friends of Angel. Ongoing support from the CFS agency was provided to Angel’s siblings and her close friends. Male “X” pled guilty to criminal negligence causing death and was given a three year suspended sentence. 55 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story FINDING ONE: Like Angel, as a result of preventable adverse childhood experiences, children and youth across Manitoba continue to experience ongoing levels of compounding trauma that are now reaching crisis proportions. This trauma crisis manifests in many forms for children and youth, including addiction, mental illness, sexual exploitation, and preventable manners of early death. As early as 21 months old, Angel was exposed to numerous adverse and traumatic childhood experiences that were not appropriately identified or addressed. This is an issue seen not only in this one case, but on a systemic level in Manitoba. The positive and negative experiences that children have while they are growing and developing influence and predict many aspects of their future experiences. It is well-established that “…childhood experiences have a tremendous, lifelong impact on our health and the quality of our lives” (McCain, Mustard, & McCuaig, 2011).5 Throughout Angel’s life, the CFS interventions and services she and her family received were inconsistently offered, crisis-driven, if at all, and did not respond in a holistic way to the needs of her family. When examining Angel’s life story, it is evident she had significant adverse and traumatic childhood experiences. Angel was exposed to persistent and ongoing sexual/physical/emotional abuse, neglect, mental illness, bullying, violence, 5 See infographic: https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html 56 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story addiction, school inconsistency, difficulty making friends, and housing instability. She had limited opportunities to experience safe and healthy situations, develop secure attachments, or to thrive. Adverse childhood experiences (ACEs) are not just about dramatic events; day-to-day interactions in children’s lives are significantly predictive and the research is clear: Chronic exposure to maltreatment, poor parenting, and other adversity is more damaging to developmental health than an individual occurrence of maltreatment (Boivin, Michel, & Adverse childhood experiences (ACEs) can be defined as, “…childhood events, varying in severity and often chronic, occurring in a child's family or social environment that cause harm or distress, thereby disrupting the child's physical or psychological health and development.” (Kalmakis & Chandler, 2013) Hertzman, 2012). Wide-scale and global studies on ACEs have been ongoing for more than two decades. Their findings are important and conclusive. For instance, studies conducted on the effects of ACEs as they relate to child and adolescent functioning note that while single traumatic events can be impactful, there is a compounding effect when an individual experiences multiple traumas or repeated traumas while they are young and developing. Multiple adverse experiences are associated with an increased risk of mental health challenges, behavioural problems, risk-taking behaviours, and early death. ACE studies today examine 14 types of adverse experiences, which are known to negatively impact a child (Finkelhor, Shattuck, Turner, & Hamby, 2013). Notwithstanding the lack of appropriate documentation by service providers involved in Angel’s life, it is clear that before her death, Angel experienced at least 13 of the 14 adverse experiences that can cause complex trauma, including: emotional, physical, and sexual abuse, physical and emotional neglect, household mental illness, property victimization, peer victimization, exposure to community violence, poverty, parental addiction, below-average grades, and a lack of peer friendships. MACY’s Youth Ambassador Advisory Squad (YAAS) told our Youth Engagement Coordinators that they want the public who are reading this to know: The trauma that young people experience is due to both the abuse and the emotional impacts to them long after they exit sexual exploitation, which include: shame, blame, guilt, and stigma attached to being sexually exploited. The public should know that in many cases they were born into poverty and addictions in their family and these challenges have guided their lives to date; they have not seen any other way of life. Too many people think people who are being exploited are “choosing” the exploitation. But really, they don’t choose to be hurt every day, they just want to have what they need to live and in cases of addiction – they think they need drugs to live. People who are being exploited should be provided with supports who are not judgmental and who do not expect them to sit in a room at a certain time every week (Interview, YAAS members, November 27, 2018). 57 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story From the earliest studies of ACEs, research has shown that experiencing six or more of these adverse life experiences is associated with a twofold increase in the risk of premature death (Dube, 2006). The pyramid below is the conceptual depiction of the many studies that have been conducted confirming the links between ACEs and the possible negative outcomes as people grow. As Anda (n.d.) explains: During the 1980s and early 1990s information about risk factors for disease had become widely known. However, risk factors such as smoking, alcohol abuse, and obesity for common diseases are not randomly distributed in the population. The ACE Study was designed to answer the question: “If risk factors for disease, disability, and early mortality are not randomly distributed, what early life influences precede the adoption or development of them?” The ACE Pyramid depicts this conceptual framework. By taking a whole life perspective the ACE Study began to progressively uncover how childhood stressors (ACEs) affect health and social well-being throughout the lifespan. Early Death Disease, Disability, & Social Problems Source: The Centres for Disease Control and Prevention The ACE Pyramid Adoption of Healthrisk Behaviours Social, Emotional, & Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences The impact of adversity on children is real and longstanding. We witness these impacts every day in our work as advocates and service providers in Manitoba. Children who experience maltreatment may also experience problems with emotional and behavioural self-regulation, which can lead to a number of challenges, including: excessive anxiety, depression, aggression, impulsivity, substance misuse, emotional instability, suicidality, self-destructive behaviour, and disruptive behaviour. 58 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Furthermore, childhood physical and sexual abuse has been associated with further victimization in adolescence (Messman-Moore, Walsh, & DeLillo as cited in, Youth in Care with Complex Needs, March 2012). As described in the images in this section, links are established between adverse experiences in childhood and a host of negative outcomes. These outcomes, whose likelihood increase as more ACEs are experienced, include poorer health and increased rates of disease, greater prevalence of drug misuse and other risk behaviours, and shortened life potential as seen in lower rates of school completion, lower career achievements, and beyond. It is, therefore, of vital importance for service providers across our province to understand ACEs, how to identify them, appropriately intervene, and help children make sense of their experiences so they are protected and supported when they experience adversity. The lack of training and skills in this area was a significant gap for the service providers involved in Angel’s life. This certainly contributed to the lack of regard for the severity of the abuse she experienced and the ineffective responses by service providers across several public service systems throughout her life. Source: Centres for Disease Control and Prevention, 2016 (Source: Kominiak, 2016) 59 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Quality mental health therapy is one intervention that can support children to understand and overcome their traumas. The need for mental health treatment was consistently identified throughout Angel’s life; it was identified as early as age seven and was recommended by various service providers at least 24 times over 10 years in the files our office reviewed. It is frustrating, then, to learn that there was little or no follow through on these critical recommendations by service providers. Near the end of her life, we believe Angel may have attended some mental health visits from federally-funded personnel while she was in Community #1, however, our office requested verification of this from federal health and our request was denied. What is clear is that for the most part and as a small child, Angel was left unsupported and on her own as she carried and sought to make sense of her multiple traumas. The service providers involved in Angel’s life did not properly identify her experiences of trauma and they did not view these as having a compounding effect on her ability to thrive. When she was young, these adverse experiences were sometimes documented but largely ignored. Then, when her trauma began to manifest in predictable behaviours such as aggression, addiction, and self-harm, the language service providers used in file recordings increasingly blamed Angel as she lived out the effects of her unresolved trauma. Angel’s experiences were not examined through a trauma lens and were not seen as interconnected and as having a broad impact across many areas of her life. Improved awareness on ACEs is needed in Manitoba, and then improved intervention options must be available to ensure the children and youth who need comprehensive and multi-faceted supports are able to receive them, and receive these early in life before the predictable negative outcomes are allowed to manifest. The various crises in Manitoba which are sometimes called a “meth crisis” or a “mental health crisis” or a “housing crisis” or a “domestic violence crisis” are all rooted in the trauma crisis that is being experienced by countless Manitobans. What is desperately required is immediate guidance from subject matter experts and decisive leadership from all levels of government to use the large available body of research on ACEs to create an education and intervention plan so that service providers have the education and tools they need to ensure children, youth, and families receive the interventions required to stem the tide of trauma-driven negative outcomes. In Angel’s life, this would have improved the ability of the service providers involved with Angel to facilitate proper assessment, planning, and therapeutic services for her as the victim of substantive sexual abuse and exploitation. RECOMMENDATION ONE: Adverse Childhood Experiences The Manitoba Advocate for Children and Youth recommends that Manitoba Education and Training, Manitoba Families, Manitoba Justice, and Manitoba Health, Seniors and Active Living engage with experts in childhood trauma and Adverse Childhood Experiences (ACEs) in order to develop a trauma prevention and response plan of action to (a) educate service providers and the public on ACEs, and (b) create appropriate, accessible immediate and long-term evidenceinformed interventions to address the trauma crisis that is ongoing in Manitoba. 60 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story FINDING TWO: The province of Manitoba’s sexual exploitation strategy has neither a multidisciplinary continuum of care, nor adequate resources to ensure early intervention and appropriate evidence-informed responses to co-occurring challenges for youth like Angel who are sexually exploited (e.g. experiencing sexual exploitation and abuse, mental illness, cognitive vulnerabilities, or addictions). As you read this, as in Angel’s case, hundreds of children and youth are being sexually exploited across our province. It is a heartbreaking and desperate truth that here in Manitoba, adults actively prey on, demand, and routinely purchase sex with children. MACY’s Youth Ambassador Advisory Squad (YAAS) told our Youth Engagement Coordinators that they want the public who are reading this to know that exploitation is not a choice. Adults who exploit children and youth are luring children as a way for them to: Get food, shelter and clothing. If they are struggling with addictions that have not been addressed, they may look for ways to make money to feed their addictions. One youth described to us how addictions rule your thoughts and that when you are in the throes of an addiction you will do anything to feed the monster (Interview, YAAS members, November 27, 2018). As the YAAS members highlighted above, many children are initially exploited by adults through survival sex in exchange for shelter, food, and other necessities. For example, during the winter, children and youth cannot survive outside. Adults know this and will often manipulate and sexually exploit children and youth in exchange for shelter. This violates their rights as provided in numerous international conventions, including the United Nations Convention on the Rights of the Child. As provided in Manitoba’s Child and Family Services Standard 1.3.5, child sexual exploitation is “The act of coercing, luring or engaging a child, under the age of 18, into a sexual act and involvement in the sex trade or pornography, with or without the child’s consent, in exchange for money, drugs, shelter, food, protection or other necessities.” Child sexual exploitation (CSE) is child abuse. In some cases it also amounts to human trafficking or procuring (“pimping”). Every year, hundreds of children and youth are exploited for the purpose of sexual exploitation in Manitoba. Unlike in the past, when the visible sex trade consisted of street-level exploitation and represented approximately 80-% of cases, today, sexual exploitation is rarely visible at the street level. If one knows where to look, sexual exploitation is visible online. Based on the feedback our office received from sexual exploitation experts in the field, approximately 80% of SEY are currently exploited online. The remaining 20% are now exploited indoors and away from public view. Approximately 400 children and youth are identified as exploited and provided services in Winnipeg every year. This is the tip of the 61 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story iceberg. Hundreds more are exploited throughout the remainder of the province. Furthermore, as in Angel’s story, hundreds of SEY are not being identified at all, particularly those in CFS care (Manitoba Families, unpublished(a), p. 11; New Directions, 2005). Every day, children and youth in our province are being lured into sexual exploitation:  Online luring and grooming via website, social media platforms, and apps (e.g. Facebook, SnapChat, and Plenty of Fish).  At school  At restaurants, malls, and stores where they can access the internet  By family members, friends and peers, in hotels, and  On the streets. Sexual exploitation often goes unreported, undetected, and is known to be a hidden crime. Notwithstanding, we do know that:  Children and youth in Manitoba are forced to enter the visible sex trade sometimes as early as [8 or 9] years old;  It takes an average of three years and seven attempts for exploited children to exit the sex trade.  Of those exploited in the visible trade, approximately 70% are Indigenous and approximately 80% are female; and  The vast majority have experienced previous physical/sexual abuse, live in situations of poverty, family violence and addictions, and have been involved with the justice system as well as Child and Family Services (Manitoba Families, unpublished(a), p. 11). As Angel’s story reveals, there are considerable gaps and challenges in service. This is particularly the case for youth transitioning out of care, and adults and individuals experiencing inter-related cooccurring challenges (e.g. sexual exploitation, substance abuse, trauma, mental health, and cognitive vulnerability). The vulnerability of youth aging out of care to sexual exploitation is corroborated by research. A 2014 study by the Alliance Against Modern Slavery found that the average age reported for the majority of trafficked persons for the purpose of sexual exploitation was between 15 and 24 years old (Sapoznik et al., 2014, p.16) It is alarming that the sexual exploitation of youth in Manitoba is being detected years after it begins, if at all. As the diagram below from Best Practices to End Sexual Exploitation and Sex Trafficking in Manitoba (Manitoba Families, unpublished(a), p. 24) demonstrates, on average, youth are being sexually exploited for at least two years before the adults in their lives intervene. When we zoom out to consider that there 62 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story are approximately 4,000 youth per year who are sexually exploited in our province, the implications of this lack of early detection, prevention, and intervention, are extremely concerning. Exploitation is Not Being Detected Early Enough The Department of Families’ recent research corroborates international studies in finding that, on average, sexual exploitation begins at age 13 but is not detected before age 15. As evidenced in the chart below, children as young as eight years old are being sexually exploited here in Manitoba. Age Identified or Assessed as Sexually Exploited Youth (SEY) n=282 Male Female 3.5% .4% .4% .4% 2.1% 4.6% Unknown Age 8 Age 9 Age 10 Age 11 Age 12 10.3% Age 13 19.1% Age 14 22.7% 19.9% 16.7% Age 15 Age 16 Age 17 Manitoba Families, unpublished(a), p. 241 Research has identified several risk factors for sexual exploitation (Gorkoff & Runner, 2003; Berry, Runner, Hallick, Rocke & Scheirich, 2005; Coy, 2009; Twill, Green & Traylor, 2010; Lloyd, 2011; Reid, 2011; Pearce, 2011; Kubasek &. Herrera, 2015; Ontario Native Women’s Association, 2016). The most common indicators, in no particular order, are as follows: 1. Childhood sexual/physical abuse 2. Being female 3. Cognitive and/or developmental disabilities 4. Mental health challenges 5. Family violence/instability 6. Physical health issues 7. Parental substance/alcohol misuse 8. Neglect 9. Difficulties in school 10. Parental involvement in the sex trade/intergenerational exploitation 11. Lack of belonging/self-esteem 12. Poverty 13. Systemic issues (being a racialized person, involvement with child and family services, being a person over represented in the justice system, etc.) 63 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story 14. Substance/alcohol misuse 15. Chronically reported missing At age 7, Angel demonstrated nine of the 15 most commonly identified risk factors predictive of sexual exploitation. By the time she reached 11 years of age, she was presenting with 14 of the 15 risk factors, yet sexual exploitation was still not identified as a considerable risk to this child, nor was there any plan in place to mitigate this risk. From age 12-17, Angel experienced numerous admissions and discharges from semi-secure facilities; crisis stabilization; and medical facilities, due to substance and solvent misuse, and suicide attempts. Between August 2010 and May 2014, Angel lived in 15 placements. She became a permanent ward on December 8, 2013. An individual child assessment was never completed by the CFS agency, with Angel (personal communication with CFS agency staff, July 20, 2017). Permanency planning did not occur, despite the October 24, 2013, case particulars mentioning, that the CFS agency had to begin permanency planning for Angel. Decisions the CFS agency made for Angel, were not made based on any assessments; there were missed opportunities to understand her risks, needs and strengths, and plan effectively. Throughout Angel’s life, indicators of sexual exploitation went repeatedly undetected by the CFS agency and other service providers with whom she interacted. This need not have been the case. Training to help detect indicators of sexual exploitation exists and is available to CFS workers and other service providers in Manitoba.6 Further, risk assessment tools on sexual exploitation exist, including a Manitoba-made example: the Transition, Education and Resources for Females (TERF) Sexual Exploitation Risk Assessment Tool (formerly known as Ndaawin Risk Assessment): In 2005, the Transition, Education and Resources for Females (TERF) program of New Directions for Children, Youth, Adults and Families, launched Canada’s first Sexual Exploitation Risk Assessment Tool. Since 2005, this tool has been used by TERF staff as a central piece in their youth and mentor programs for assessing levels of exploitation. Part of the referral process into TERF is to also have the participant’s social worker complete the assessment tool. The stages of exploitation framework — at risk, transitioning, entrenched, and transitioning away — was created with clear indicators by Jennifer Richardson (Berry) and Jane Runner. This framework is 6 A core training course on understanding and working with sexually exploited youth is offered in Manitoba through New Directions for Children, Youth, Adults and Families’ Transition, Education & Resources for Females (TERF) program. For more information, see http://newdirections.mb.ca/training-education-programs/terf-transitioneducation-resources-for-females/. New Directions also offers The Kappapako Miikiwaap Lodge Teachings Training Course focused on preventing the sexual exploitation of children and youth. Additional training is offered by the Winnipeg Police Service, the Canadian Centre for Child Protection, and a number of community agencies. 64 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story taught in the provincial core training on “Understanding and Working with Children and Youth who have been Sexually Exploited/Trafficked”, a course for professionals who work with or care for sexually exploited children and youth (e.g. social workers, foster parents, educators, health care professionals, probation officers, and police officers). In addition, StreetReach started using this tool in 2013 to help assess new referrals for potential High-Risk-Victim (HRV) status. The tool was tested in 2015 and the Sexual Exploitation Unit assessed its margin of error to be below 2% in 2017. TERF’s Risk Assessment Tool is designed to support best practices in responding to sexual exploitation so that practitioners, agencies, and stakeholders are better equipped to:  Identify sexual exploitation;  Develop a more accurate understanding of the risks for the child/youth;  Gather information on the scale and scope of sexual exploitation;  Inform appropriate intervention and supports for the individual based on their stage of exploitation; and  Inform more general evidence-based responses and actions for this population. (Manitoba Families, unpublished(a), p. 25) As Angel’s story reveals, sexually exploited youth (SEY) have co-occurring challenges and require more complex recovery supports. TERF’s risk assessment tool above helps ensure early detection and intervention based on the SEY in question’s needs and stages of change. What that means is that these youth face a multitude of challenges, such as, addictions, cognitive impairments, learning disabilities, developmental delays, and mental illnesses, and this tool can be of great assistance to inform evidencebased responses by service providers. In the yet-unreleased report, Collaboration and Best Practices to End Human Trafficking and Sexual Exploitation in Manitoba (Manitoba Families, unpublished(a)), the following chart shows that sexually exploited youth had an average of four different co-occurring issues. Sexually Exploited Youth Have Co-occurring Challenges Each sexually exploited youth (SEY) had an average of four different co-occurring challenges in one or more of the following four combined categories in CFSIS [the Child and Family Services Information System/computer file database]: learning disabilities, developmental delays, cognitive impairments, and mental health conditions. For the same 148 SEY:  130 (87.84%) had one or more learning disabilities,  54 (36.49%) had one or more developmental delays,  69 (46.62%) had one or more cognitive impairments, and  47 (31.76%) had one or more mental health conditions. 65 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Co-ocurring Diagnoses for Sexually Exploited Youth n=148 87.84% 31.76% Mental Health 46.62% Cognitive 36.49% Developmental Delay Learning Disability Manitoba Families, unpublished(a), p. 21 These challenges cannot be addressed in isolation of one another. Appropriate resources are needed to address co-occurring conditions. The U.S.-based Substance Abuse and Mental Health Services Administration (SAMHSA) states that: The consequences of undiagnosed, untreated, or undertreated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death. People with co-occurring disorders are best served through integrated treatment. With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes. Increasing awareness and building capacity in service systems are important in helping identify and treat co-occurring disorders. Early detection and treatment can improve treatment outcomes and the quality of life for those who need these services (Substance Abuse and Mental Health Services Administration, 2016). Meeting the needs of youth who are sexually exploited should involve a multi-dimensional response that is thoughtful and evidence-informed, including tools like the risk assessment on sexual exploitation by TERF described above. Moreover, addressing sexual exploitation requires a range of services. There are different stages of exploitation – at risk, transitioning in, entrenched, and transitioning away – each of which necessitate different responses (Berry, Runner, Hallick, Rocke, & Scheirich, 2013). Responses also need to be tailored to meet the youth in question where they are at in terms of their stage of change – pre-contemplative, contemplative, preparation, action, and maintenance (Berry et al., 2013). This continuum of services requires a range of interventions, from primary prevention to providing assistance in exiting, healing, and support for those already involved. An intervention that Angel could have benefitted from were the services of StreetReach and the Winnipeg Outreach Network (WON). These street-level outreach services continue to not be provided in rural communities. 66 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story As the Commercial Sexual Exploitation: Innovative Ideas for Working with Children and Youth (2002) report emphasizes, a comprehensive continuum of services for commercially sexually exploited children and youth consists of service provision in these key areas:  Global prevention strategies: Addressing systemic issues Children and youth who are being commercially sexually exploited will require a range of services specifically tailored to their unique circumstances, and their progress towards exiting may require several attempts. such as racism, sexism, social inequity, etc., through social policies;  Targeted prevention: Effective programming targeted Commercial Sexual exploitation: Innovative Ideas for Working with Children and Youth. March 2002. p. 29. towards those most at risk;  Harm reduction: Aimed to reduce the risks children and youth may experience while they are being sexually exploited;  Early Intervention/Crisis intervention: Designed to prevent the entrenchment of children and youth in sexual exploitation;  Programs to assist leaving: Designed to ensure that the child is not continually exploited and is able to exit the sex trade in a supported understanding environment that can meet their complex needs; and  Programs to assist healing and reintegration: Long-term support for the youth’s healing journey (Justice Institute of British Columbia, 2002). The Manitoba Strategy Responding to Children and Youth at Risk of, or Survivors of, Sexual Exploitation (2004) was launched by the Manitoba government’s Healthy Child Committee of Cabinet in 2002. Phase two of the provincial strategy, known as Tracia’s Trust was subsequently launched in 2008, so-named in honour of a young girl, Tracia Owen, who died by suicide in 2005 at the age of 14. Originally from the community of Little Grand Rapids, Tracia had been a permanent ward of CFS and experienced many adversities in her short life, including a known history of being sexually exploited by adults in Winnipeg. Tracia’s death and the services she had been provided prior to her death were also the focus of a public inquest in Manitoba, which released its final report in January 2008. The final report of the inquest (Guy, 2008) focused significantly on sexual exploitation of children in Manitoba. In that report, the Honourable Judge John Guy stated: It is conceded that the sexual exploitation of our youth is a serious problem in our city…[There] is no doubt that more needs to be done when we hear that 400 children a year are being exploited in the visible sex trade and even more in the invisible sex trade. In some way public awareness must be raised so the public accepts the fact that sexual exploitation of addicted youth is child abuse, is unacceptable and must be combated strenuously….These individuals are victims and the public has to understand their needs (Guy, 2008, p. 6). 67 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story As noted, Manitoba’s Strategy to combat child sexual exploitation was launched in response to stories of sexually exploited children and youth that mirrored those of young Tracia Owen. Our office has also learned that this Strategy came to fruition as a result of considerable community and survivor-led mobilization. Today, as part of its online resources, the Tracia’s Trust website lists a continuum of services, including community-led initiatives, to respond to the varied needs of children and youth who are sexually exploited.7 However, the website has not been updated since 2013 and it’s not clear what initiatives are ongoing. In addition, many of the ongoing initiatives have not been updated or evaluated since they were launched in 2002 or 2008, when the nature of sexual exploitation was different (e.g. methamphetamine was not so wide-spread and prevalent). It is concerning that much of the Strategy appears to be wellintentioned, but not grounded in evidence of meaningful interventions or in accountability in terms of clear outcomes and outputs for children and youth in Manitoba. As an office that works with exploited youth every day, we are concerned by the reports our office is receiving about the gaps in resources for sexually exploited youth at the local, provincial, and national levels, including:  A lack of appropriate placements for SEY with co-occurring needs,  No harm reduction framework for SEY struggling with addictions,  SEY with cognitive vulnerabilities do not have resources they need,  SEY are being placed with other youth who further exploit them,  There is a lack of transition planning for SEY who age out of care, and  Unclear outcomes in terms of what the province is doing in the areas of prevention, intervention, healing, and reintegration. Our office is encouraged that the government continues to work with approximately 10 regional teams across the province. However, at present, the vast majority of initiatives are in Winnipeg. It is concerning that SEY must, in many cases, leave their First Nations, rural and/or remote communities to get help. In cases this office is aware of, some youth are further exploited when they come to Winnipeg as a result of not having community and family supports. Examining and evaluating the range of services under Tracia’s Trust is needed, to ensure that existing programs are, in fact, addressing the needs of children and youth who are sexually exploited. 7 http://www.gov.mb.ca/fs/traciastrust/continuum.html provides an out of date list of continuum of services. 68 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story In 2016, the Child and Family Services Division embarked on a research project to “analyze data to further understanding on sexual exploitation and human trafficking, and improve service responses for vulnerable Manitobans in these situations” (Manitoba Families, unpublished(a), p. 7). Titled, Collaboration and Best Practices to End Human Trafficking and Sexual Exploitation in Manitoba, the goal of this report was to inform “Tracia’s Trust (the Strategy) to more effectively counter and prevent human trafficking and sexual exploitation in Manitoba” (Manitoba Families, unpublished(a), p. 14). Since the Strategy began 16 years ago, Manitoba has been able to gather data from multiple sources and databases. The objectives of the Manitoba Families report were to:  Provide evidence-based insights on current investigations, co-occurring phenomena, system gaps, placement dynamics, offenders and the incidence of sexual exploitation in Manitoba;  Identify important trends;  Inform training;  Formalize emerging best practices;  Inform policy developments, program evaluations and accountability;  Inform future research, capacity building programs, resources and projects;  Inform a proactive, upstream approach;  Serve as an education, prevention and awareness tool for the general public;  Inform the establishment of a program logic for Tracia’s Trust; and  Guide evidence-based measuring, evaluating and learning for phase 3 of the Strategy (Manitoba Families, unpublished(a), p. 21). The Manitoba Advocate for Children and Youth was provided copies of this report from multiple sources. It is clear that a lot of time, effort, and research was put into this project. Valuable recommendations have been made to more effectively address the issue of sexual exploitation in Manitoba. The timeline stated in the research report includes public dissemination in September 2017. As of December 2018, this research has yet to be released publically. 69 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story RECOMMENDATION TWO: Sexually Exploited Youth The Manitoba Advocate for Children and Youth recommends that the Department of Families, in collaboration with Manitoba Education and Training, Manitoba Justice, and Manitoba Health, Seniors and Active Living, in consultation with Manitoba Status of Women, Indigenous and Northern Relations, the Winnipeg Police Service and the Royal Canadian Mounted Police, (1) expand StreetReach, Winnipeg Outreach Network (WON), and culturally appropriate services in First Nations and rural and remote communities; and (2) independently evaluate and then update Tracia’s Trust: Manitoba’s Sexual Exploitation Strategy. DETAILS: These activities should include:  The release of the Department of Families’ research entitled, Collaboration and Best Practices to End Human Trafficking and Sexual Exploitation in Manitoba;  Ongoing data collection to inform clear performance measurements reflected in service purchase agreements (SPAs);  An independent third party external evaluation of the outcomes and outputs of the Strategy to be published upon completion. This evaluation should utilize the Department of Families’ research and specifically include analysis of existing o specialized group and foster care placements for sexually exploited youth, o crisis stabilization support for sexually exploited youth, o sexual exploitation investigations, o regional teams funded by Tracia’s Trust, o provincial training on the sexual exploitation of children and youth, o the effectiveness of the Strategy for children and youth who are not in care; and o the effectiveness of the Strategy in Indigenous communities as per Indigenous methods of evaluation;  A pilot of TERF’s Sexual Exploitation Risk Assessment Tool across the four Child and Family Services Authorities;  The development of a continuum of care informed by youth consultation and collaboration with Indigenous partners (e.g. Manitoba Keewatinowi Okimakanak and Southern Chiefs’ Organization) to create/reform service programs to address the co-occurring needs of sexually exploited youth (e.g. mental health, addictions, justice, and education); and  An expansion of StreetReach (including youth who are not in care), the Winnipeg Outreach Network (WON), and services for youth who are sexually exploited in First Nations and remote and rural communities. The expansion of each of these services should be paired with continuous quality improvement tracking tools to monitor outcomes, track progress towards service delivery goals, and respond to the evolving needs of sexually exploited youth. 70 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story FINDING THREE: More needs to be done to raise public awareness about the ongoing demand for purchasing sex from minors and the relentless sexual exploitation of children and youth in Manitoba. In Manitoba, “buying sex from children is considered child abuse” (Canadian Centre for Child Protection, n.d.). It is therefore unacceptable that services providers and the general public continue to imply that children and youth – who cannot legally consent to an exchange of sex for money or other gain– are “choosing a lifestyle,” are “prostituting” or are “exploiting” themselves. Instead, the firm and decisive message must be that adults must not buy sex from children. This position needs to be set by government and community leadership, understood and reinforced in all of our minds and in the ways we speak about young people who are being exploited by adults in our communities. Sex with children is abuse and children and youth who are involved are victims of sexual abuse. They must be viewed as such and cared for so they can be protected from ongoing harm. Sexually exploited children and youth are not to blame for the abuse they live up to 20 times a day. Many of these children and youth are controlled by pimps and experience ongoing threats and violence. Canada’s National Inquiry into Missing and Murdered Indigenous Women and Girls (MMIWG) and numerous reports (Razack, 2000; Sethi, 2007; Sikka, 2009; Ontario Federation of Indigenous Friendship Centres, 2013) have described the systemic racism and gendered discrimination of Indigenous women and young girls that contributes to the higher incidence of sexual exploitation and trafficking of Indigenous women and girls. For example, a report by the Ontario Native Women’s Association (ONWA) (2016) revealed that “violence against Indigenous women and girls (is linked) to pervasive stereotypes and the normalization of colonial violence.” (p. 2) Further, Indigenous women and girls like Angel continue to be blamed for the violence perpetrated against them. As ONWA emphasizes, “there is a general societal reluctance to view Indigenous women as victims; rather they are often cast as complicit in their situations” (p. 6). This victim blaming of SEY is apparent after reviewing the circumstances in Angel’s life. Indeed, consistent messaging within the documents included in our review demonstrates that many of the services in Angel’s life positioned her as “complicit” in the abuse that was perpetrated against her. One such example, although certainly not the only one, was when, at the age of 16, RCMP located a missing Angel who was intoxicated and being sexually assaulted. The response from officers reveals a tragic lack of understanding of the dynamics of exploitation in that the perpetrators were ignored and Angel was charged with alcohol consumption. Similarly, there does not appear to have been any response or follow up from the CFS agency. As adults, we must do better. Each of us who work with youth, or who care about youth, owe it to them to educate ourselves about issues such as exploitation because children and 71 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story youth who are being abused in these ways are often unable to clearly ask for help. Tragically, many of them do not understand exploitation for the abuse that it is. Many young people do not know that exploitation is abuse – middle school children need to be made aware of the dangers of exploitation because by the time they are being exploited it’s too late, especially if they become exploited to feed an addiction. (Interview, YAAS members, November 27, 2018). One youth who sits on MACY’s Youth Ambassador Advisory Squad (YAAS) spoke about getting drugs for free from an abuser and was then told that the drugs weren’t free and she had to “work it off.” (Interview, YAAS members, November 27, 2018). Situations like these are taking place every day in our province. We all have a role to play in taking action to make our communities safer for youth and for exposing and punishing adults who have sex with children. By the time Angel reached 11 years old, she had been subjected to countless different types of abuse, with little or no response from the systems responsible for ensuring she was safe. It is not difficult to imagine that Angel might have normalized the abuse and the lack of response from adults, which would have reinforced that she was not worthy of being protected. ONWA (2016) stated that “the normalization of physical and sexual violence of Indigenous women, through almost commonplace occurrences of sexual violence may make Indigenous women and children come to expect to be sexually exploited, and consider it a part of ‘normal life’” (p. 9). This description would fit Angel’s circumstances beginning in infancy and continuing throughout her entire life. Richardson (2018) found that a child’s risk to sexual exploitation can be reduced if the child understands that they are a part of their community, and that their community is a part of them. This special report has demonstrated that Angel did not have this sense of belonging, nor was she provided an opportunity to reclaim her place in the community or allow her community to have a place within her. Brokenleg (2012) states it best when discussing how to “transform cultural trauma into resilience” (p. 9). In describing resilience, Brokenleg notes: Resiliency is being strong on the inside, having a courageous spirit. One cannot teach resiliency with words or posters. What we need are transformative experiences. Here are four simple examples, which show the match between findings of pioneer researcher in self-worth, Stanley Coopersmith (1967) and the four Circle of Courage dimensions of Belonging, Mastery, Independence, and Generosity: 1. Significance: Realizing that one matters to others creates enormous strength inside of that person. This describes the spirit of Belonging. 72 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story 2. Competence: A capable human being can learn, solve problems, and develop talents and abilities. Such is the joy that comes from Mastery. 3. Power: This is not power wielded over others, but the ability to control one’s emotions and set the course of one’s destiny. This is true Independence. 4. Virtue: Ultimately, one cannot know that he or she is valued unless he or she is of value to others. This is the spirit of Generosity (Brokenleg, 2012, p. 12). What was also significantly absent in Angel’s story was a recognition of her belonging to a Cree community and how an Indigenous approach/model to healing and wellness could have been transformative or have helped support her in a path of healing. Our office located no recordings or other evidence of any offers being made to her to explore this piece of her identity, nor offers made for her to meet with an Elder or other spiritual healer. Furthermore, there are no records indicating that assessments were completed through a cultural lens. Berry et al. (2003) found that family members, guardians, community members, front-line service providers, and law enforcement often do not recognize the needs of SEY. Further, SEY experience shaming and blaming by mainstream society, which does not understand the trauma and abuse they are experiencing. As a result, SEY can become further entrenched in the sex trade, for it is there that they experience a greater sense of social and cultural belonging. From the documentation reviewed, it is clear that Angel was blamed for the behaviors that were a result of the sexual abuse she experienced for most of her life. Workers who were mandated to protect her did not protect her on a number of occasions, did not accurately assess the risk to her wellbeing and safety, did not adequately intervene, and did not access appropriate resources for Angel. Our investigation also found that Angel described not feeling like she belonged and not feeling like she could succeed in many areas of her life: school, family, community, placements, and others. Richardson (2018) described what happens to children when service providers, police, CFS workers, and parents or guardians blame the child for the exploitation being perpetrated against them. The author found that the blame from adults reinforces the message that children and youth receive from exploiters/traffickers/pimps, a message intentionally used to manipulate the child or youth, specifically, “that they will never be accepted in mainstream society” (p. 10). Children who experience stigma and who feel a lack of understanding from the people who are responsible to protect them, feel that they are not worth enough to belong anywhere else other than with their exploiters. It can simply begin to feel easier for the child to live immersed in the exploitation and abuse where they are not being subjected to the shame or blame of outsiders (Berry et al., 2003). As in Angel’s story, it is unacceptable that children are being blamed by service providers and other adults for continuing to return to where they are 73 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story getting some semblance of their needs met, such as feelings of love (however illusory), belonging, acceptance, numbing via drugs or alcohol, and beyond. The Manitoba Advocate urges the public to consider that if there were not a demand for purchasing sex or sexually exploiting children and youth in Manitoba, there would not be a supply of youth who fall prey to this egregious human rights violation every year in our province. In Manitoba, we are fortunate to have experts and community leaders who are mobilized on the issue of sexual exploitation and who are working to end the commercial sexual exploitation of children. One campaign, Stop Sex With Kids, is operated by the Canadian Centre for Child Protection. The campaign’s website and materials are valuable resources for each Manitoba citizen who wants to know more about the prevalence of this issue and what must be done to stop this form of child abuse.8 Tracia’s Trust Stop Sex With Kids Campaign Source: Canadian Centre for Child Protection Continued multidisciplinary collaboration is needed to bring together experts to collaborate and share information. One such project would be updating existing statistics to ensure current data inform policy and program decisions. Angel’s case, and those of the hundreds of SEY in our province, reveal that much more needs to be done to raise awareness about the ongoing exploitation of children and youth in Manitoba and to hold those who sexually exploit children accountable. 8 See more online: http://www.stopsexwithkids.ca/app/en/ 74 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story RECOMMENDATION THREE: Sexually Exploited Youth The Manitoba Advocate for Children and Youth recommends that Communication Services Manitoba, Manitoba Education and Training, Manitoba Families, Manitoba Justice, Manitoba Health, Seniors and Active Living, Manitoba Status of Women, and Manitoba Indigenous and Northern Relations collaborate with youth advisory groups, the Canadian Centre for Child Protection, Winnipeg Police Service, Royal Canadian Mounted Police, Indigenous and community organizations, and the Manitoba Advocate for Children and Youth to carry out ongoing public education via awareness campaigns that (a) denounce the sexual exploitation of children and youth and (b) raise awareness about the ongoing demand for purchasing sex and/or sexually exploiting children and youth in Manitoba. DETAILS: This plan should:  Be centrally driven by an existing inter-departmental working group such as the Deputy Ministers of Health and Social Policy and Priorities (DMHSPP) committee/Healthy Child Deputy Ministers’ Committee (HCDMC);  Consider how best to reach those most in need of its information;  Include youth, survivor, and Indigenous community consultation;  Consider if names of adults who are sexually exploiting youth should be publicly shared as is the practice in other provinces;  Be evidence-informed in terms of clear outputs and outcomes and learn from successful campaigns in other jurisdictions;  Avoid sensationalism, inappropriate imagery, or language;  Draw awareness to bystander legislation that provides that all Manitobans must report child sexual exploitation; and  Include provisions for public education and awareness campaigns that coincide with Manitoba’s Stop Child Sexual Exploitation Awareness Day every March. 75 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Article 1 of the Declaration of Principles of The Child and Family Services Act (1985) of Manitoba provides that “The safety, security and well-being of children and their best interests are fundamental responsibilities of society.” FINDING FOUR: Provisions within The Child and Family Services Act were not met regarding safety, security, well-being of Angel, or her best interests. Child and family services minimum required service standards were also not met in the areas of: assessment, case planning, service delivery, and evaluation. Failure to achieve minimum service standards is seen too-commonly in the provincial child and family services system. Accountability in service improvements is immediately required. The ways in which CFS services are to be delivered in Manitoba are set out in the Child and Family Services Standards Manual, which describes the minimum service standards that must be met by all workers in each CFS agency delegated by the Minister of Families (through the relevant CFS Authority) to deliver CFS services in the province. Overall, the expectation and requirement is that CFS services are to be delivered in a planned and consistent manner that ensures the needs of families are identified, assessed, and addressed in a way that bests supports children and families. The minimum provincial CFS standards establish the baseline of CFS work in the province. However, the ability of the system to consistently meet these minimum standards has long been viewed as an unachieved goal not only by The Advocate (Manitoba Advocate, 2018), but by many others, including the Department of Families itself. Workers not meeting minimum standards and confusion regarding minimum service standards are also concerns that have been previously examined in Manitoba by Commissioner Ted Hughes during the Phoenix Sinclair Inquiry. Throughout the involvement of CFS in the life of Angel and her family, the evidence was clear and demonstrated significant and unacceptable gaps in case management practices related to assessment, case planning, service delivery, and evaluation. Assessment Provincial Standard 1.1.2 notes the purpose of a family assessment is to determine the family’s ability to care for their children and the level of service required. Family assessments are conducted by assessing key family members, their individual characteristics and strengths, how they relate to one another and how their environment affects them. The standard states that a “family assessment is required on all open cases.” The worker must update a family assessment when there is significant change in circumstances, such as, in Angel’s case, an out of home placement is required, or a child is being returned to their family. 76 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Conducting a thorough assessment that includes all family members is the basis for case management planning. Through understanding the family in a holistic manner, a worker is in a better position to develop an effective and successful case plan. Without comprehensive assessments, workers may not have a clear understanding of the child and family’s strengths and needs. Section 1.1.2 Assessment of the CFS Standards Manual describes the rationale and objectives of conducting assessments: Assessment Process Assessment begins at the first contact and is ongoing. It involves gathering and analyzing information on the strengths, needs, and resources of a person or family including extended family and community resources. It determines what is needed to build a family's ability to care for children. Workers should encourage individuals, families and children to take an active part in identifying both the issues and the resources to meet their needs. A thorough assessment identifies key family members, their individual characteristics, how they relate to one another and how their environment affects them. An assessment must be updated regularly as circumstances change or more information becomes available, to help predict and avoid situations that may lead to abuse or neglect of children. Assessment is the basis for case management planning. A comprehensive assessment is more likely to lead to the development of a plan that is relevant, timely and ultimately successful. All factors must be assessed regardless of the services required or requested (for example, family support, child protection, adoption or post-adoption services).9 From ages 2-11 (2001 – 2010), Angel was apprehended 10 times and lived in 31 placements; she was returned to her mother’s care on 12 different occasions. Substance misuse and leaving her children unsupervised or with unsuitable caregivers, were issues consistently noted - the CFS agency was aware of the ways in which Angel’s mother was struggling to parent her children safely. Still, throughout these nine years, a critical period for the children’s’ development, there was no evidence that the CFS agency completed any of the required assessments, which would have determined Angel’s mother’s readiness and capacity to care for her children. Additionally, in May 2007 when Angel was eight years old, the mental health worker in Community #1 recommended a home assessment to monitor the wellness of Angel’s mother and her children. Again, there was no evidence the CFS agency responded to this recommendation to assess the children’s safety. 9 See: https://gov.mb.ca/fs/cfsmanual/1.1.2.html#care 77 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Without an understanding of what was happening for Angel or her family members, successful case planning was predictably unsuccessful. Conducting regular family assessments provides workers with a better understanding of the child and family’s strengths and what their needs for support may be, which is the only way effective case planning can occur. An accurate assessment of the family would likely have also identified that her mother presented with numerous risk factors for sexual exploitation, and was also likely a victim. Without a proper gathering of relevant information, the CFS agency repeatedly did not provide the supports this family required to heal from their traumas and become a healthy and cohesive family unit. Conducting risk and family assessments, analysing the gathered information, and then mobilizing the proper supports is the only way that CFS workers and their agencies can transform the CFS system in the ways in which transformation is desperately needed. The system as a whole tends to operate inside a service model of child apprehensions, when what is required to truly help families and reduce the numbers of children in care, is to embrace a service model that promotes social work practice, instead of the current service model that favours apprehensions. Agencies have a legal mandate and ethical responsibility to create permanency, safety, and well-being for families. If the CFS agency would have better understood the needs of her family, multiple apprehensions, out-of-home placements, and short-lived reunifications for Angel could have been prevented. The family deserved better. When a child is in care of a CFS agency, the CFS agency is also required to complete child assessments. A child assessment is a specialized assessment of any child to determine individual needs that are separate from the family and the permanency plan for the child. The worker must complete an individual child assessment under the following guidelines:  within 30 days of the placement of a child,  prior to returning a child to their family,  when a child has needs that cannot be managed by the family,  when a child is likely to be in care for more than six months, and in need of permanency planning (s.1.1.2 Assessment, Child and Family Services Standards Manual). These assessments must be updated, at minimum, annually. As mentioned previously, one key area that CFS should have been assessing and demonstrating a better understanding in was the area of sexual exploitation. Research has identified several risk factors for sexual exploitation (Gorkoff & Runner, 2003; Berry, Runner, Hallick, Rocke & Scheirich, 2005; Coy, 2009; Twill, Green & Traylor, 2010; Lloyd, 2011; Reid, 2011; Pearce, 2011; Kubasek &. Herrera, 2015; Ontario Native Women’s Association, 2016). The most common indicators, in no particular order, are as follows:  Childhood sexual/physical abuse  Being female  Cognitive and/or developmental disabilities  78 Mental health challenges Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story  Family violence/instability  Lack of belonging/self-esteem  Physical health issues  Poverty  Parental substance/alcohol misuse  Systemic issues (being a racialized  Neglect person, involvement with child and  Difficulties in school family services, being a person over  Parental involvement in the sex represented in the justice system, etc) trade/intergenerational exploitation  Substance/alcohol misuse  Chronically reported missing At age 7, Angel demonstrated nine of the 15 most commonly identified risk factors predictive of sexual exploitation. By the time she reached 11 years of age, she was presenting with 14 of the 15 risk factors, yet sexual exploitation was still not identified as a considerable risk to this child, nor was there any plan in place to mitigate this risk. From age 12-17 (2011 – 2015), Angel experienced numerous admissions and discharges from crisis stabilization and medical facilities, due to substance and solvent misuse, and suicide attempts. Between August 2010 and May 2014, Angel lived in 15 placements. She became a permanent ward on December 8, 2013. An individual child assessment involving Angel as a participant was never completed by the CFS agency (personal communication with CFS agency staff, July 20, 2017). Permanency planning did not occur, despite the October 24, 2013, file documentation mentioning that the CFS agency had to begin permanency planning for Angel. Decisions the CFS agency made on Angel’s behalf were not made based on any assessments; there were missed opportunities to understand her strengths, ideas, opinions, risks, and needs and the multiple opportunities to plan effectually were ignored. Case Planning The next step in a CFS agency’s involvement is to use information gathered through assessments and begin case planning. Case plans set out specific goals and service activities, with measurable outcomes. According to s.1.1.3, Planning of the CFS Standards Manual: Each and every open family service or child in care file requires a written plan. A family service file, regardless of which section of the Act it is open under, requires an Ongoing Family Plan. Every child in care file, regardless of the child’s legal status, requires a Child in Care Plan.10 At the planning stage, the case manager and key individuals identified at the assessment stage develop ways to address the needs and issues of the family and children. Based on the assessment, the outcomes of planning are: specific measurable case goals, service activities, and timelines. 10 See: https://gov.mb.ca/fs/cfsmanual/1.1.3.html 79 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story As quoted above, each open family service file requires a written plan which addresses the strengths and needs identified during the assessment phase and identifies what is required in order to strengthen the ability of a person or family to care for their children. Case plan goals aim to lessen risks and strengthen families. They must be flexible, reviewed regularly, and be revised as goals are achieved or needs change. In Angel’s file, annual case plans were completed from August 2010 to July 2015. Each plan identified presenting problems, needs, goals, service action, and evaluation. However, the CFS agency did not properly assess the needs of Angel or her family, and so, the case plans were written by the CFS agency without critical information that would have helped the family experience needed support and achieve success. As Angel got older, her unaddressed trauma manifested in predictable ways and challenging behaviours. The CFS agency began to write case plans that revealed their lack of understanding that Angel was a highly traumatised child who was in desperate need of security and support. For example, in 2014, the CFS agency wrote: “Presently Angel is still an out of control teenager who throws tantrums if situations don’t go her way, she will also lash out at people who try to reach out to help her.” CFS agency case plans at this time described that Angel needed to change her attitude and behaviours, and identified Angel as the central issue. The case plans did not reflect an understanding of the connection between the risk-taking behaviours that she was exhibiting, and the adverse childhood experiences (ACEs) that she had survived. For example, the August 27, 2010, case plan noted that, “Angel needs to comprehend the possibility of accidently killing herself when she uses suicide ideation as a means to control or manipulate others”, and the May 8, 2014, case plan indicated that, “Angel will need to start realizing her out of control behaviours are not doing her any good because it interferes [with] her daily challenges”. These statements placed blame on Angel, did not identify her needs, and served little purpose if the goal was to engage Angel in transforming her life. Children who are sexually exploited present with what is often termed in their case plans as “delinquent” or “out of control” behaviours, rather than as an extremely traumatized child who is trying to communicate that they need the adults to intervene and provide them with the adequate supports to meet their needs. Generally, people fail to realize or understand that children who are sexually exploited are being subjected to having sex with numerous adult males, numerous times a day. This is not “partying” and this is not a “lifestyle.” These children are not exploited by their own choice, but rather due to their vulnerabilities, of which Angel had many - and none of which were being effectively addressed. In Angel’s case, there were many indicators, and even several disclosures that clearly indicated she was 80 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story being sexually exploited by adult males, who more than likely knew she was a child. However, the workers who were responsible for ensuring these men did not further abuse other children, and who held the legal mandate for protecting Angel, did not move to protect her on numerous occasions. Richardson (2018) noted that several authors have corroborated that there is a lack of care and protection for children and youth who are sexually exploited within the CFS system. Richardson cites the finding by Pearce (2011) that CFS workers have often viewed children who were sexually exploited as being complicit in their own abuse because these workers believed that the children continued to wilfully engage in the sex trade. Pearce found that due to this bias, the majority of child protection workers did not make the proper attempts to protect the exploited children, citing that they had other children who were more worthy of protection. Further adding to the complexity of trauma for Angel was the amount of times she was moved from caregiver to caregiver. The number of placements Angel was subjected to – in total 46 placements by age 17 – left Angel at higher risk in her environment. While Angel’s number of placements was staggeringly high for a child, this is too-common in the CFS system. Our office regularly becomes involved in or investigates situations where children in care are moved repeatedly and often with little to no notice of a placement change. This issue on its own can lead to extremely poor outcomes for these children (Richardson, 2018). Service Delivery: Abuse Investigations From a young age, Angel was a victim of abuse. In The Child and Family Services Act, abuse is defined as: Definitions 1(1) In this Act "abuse" means an act or omission by any person where the act or omission results in (a) physical injury to the child, (b) emotional disability of a permanent nature in the child or is likely to result in such a disability, or (c) sexual exploitation of the child with or without the child's consent; (« mauvais traitements »)11 In five of the known incidents of abuse that Angel experienced and which were documented by the CFS agency to have been known, those required abuse investigations were either incomplete, or not conducted. Minimum provincial service standards were not met. Section 2 of Child Abuse Regulation 11 See: http://web2.gov.mb.ca/laws/statutes/ccsm/c080e.php 81 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story 14/9912 prescribes the specific steps the CFS agency must undertake if the agency receives information that a child is abused or may be abused. The regulation notes: (a) where there is a preliminary opinion that serious physical injury or sexual exploitation of the child has occurred, immediately consult with a duly qualified medical practitioner and where believed necessary and appropriate, arrange for a medical examination of the child and any other child by a duly qualified medical practitioner or at a medical child abuse facility; (b) notify and consult immediately with an appropriate police officer for the area as to the particulars of the case; (c) share all relevant information, including information of a confidential nature, with the police officers, medical and hospital professionals and other agencies or persons involved in the investigation and management of the case, to ensure the best course of action for the protection of the child is taken; and (d) refer the matter to the child abuse committee of an appropriate agency as set out in section 7. While visiting family in Community #1, in December 2012, Angel was sexually assaulted by an adult male in the community. A third party made the disclosure to the CFS agency, on January 6, 2013. RCMP were notified and charges were laid; Angel received victim services support. The CFS agency took the following action: contacted RCMP, interviewed Angel, and sought medical attention. The matter; however, was not referred to the child abuse committee until eighteen months later in June 2014, when the newly-hired CFS agency child abuse coordinator was sent the intake in May 2014. Section 7(1) of Child Abuse Regulation 14/99 (Government of Manitoba, 1999) states that the referral to the appropriate agency child abuse committee must be within 30 days after the agency receives this information. The opportunity for the child abuse committee to provide consultation for the management of the case, or make recommendations to protect Angel or any other child, was hampered, due to the time lapse between the incident and the referral to the committee. Agencies are responsible for determining if a child is in need of protection. The police are responsible for determining if a person has committed an offence under Canada’s federal Criminal Code (Government of Canada) or The Child and Family Services Act (Government of Manitoba, 1985): See Child Protection Offences in CFS Standard 1.3.7, Working with Law Enforcement. A CFS agency case plan, dated April 1, 2013, identified a sexual assault disclosure that Angel had made. Angel described the incident in detail in a letter to her mother (CFS file, undated). The abuse occurred in Winnipeg, in a vehicle of an unknown male. Angel did not disclose the abuse immediately and Winnipeg Police Service could not investigate further, as she was unable to sufficiently describe the alleged 12 See: http://web2.gov.mb.ca/laws/regs/current/_pdf-regs.php?reg=14/99 82 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story offender. Despite a criminal investigation not being warranted by WPS, the CFS agency should have (and was required to) conducted a child abuse investigation. Children and youth who have been sexually exploited are victims of child sexual abuse, and Angel’s risk of further sexual exploitation should have been explored. This was also a missed opportunity for the CFS agency to communicate to Angel that the exploitation and sexual assault was not her fault, as she could not consent to being exploited or sexually assaulted. It is not evident that Angel understood her worth as a person and her right to be protected from exploitation, as the letter she wrote to her mother disclosing the assault was written in part, as an apology from Angel and a plea that her mother not be angry with her for the sexual assault. Increasing the knowledge and skills of people working with children affected by sexual exploitation, would increase the success in intervening with those at risk. In February 7, 2015, Angel and another foster child were located by RCMP, at a residence in Steinbach. Angel was deemed intoxicated. RCMP found Angel lying on a bed with an older male on top of her, “almost being sexually assaulted.” This use of language is concerning and the Manitoba Advocate is not clear how RCMP can locate an adult male on top of an intoxicated child and conclude that the child is only “almost being sexually assaulted.” Indeed, the language used minimizes what Angel experienced. Angel was 16 years old at the time. The male involved was an adult and in a position of power. If she was intoxicated, she could not consent as provided in the Criminal Code of Canada. Both girls were kept in police custody until deemed sober and charged with underage alcohol consumption. The designated CFS intake agency was notified and the information was forwarded to the CFS agency, however, there was no follow up documented on file. What was required at this point was that a referral should have been made to the CFS agency’s child abuse coordinator for review. Workers must understand the definition of abuse, and when a referral to the abuse coordinator is required. Failure to do so, as in this case, increased Angel’s risk for further sexual exploitation, and may have placed other children at risk. The Canadian Centre for Child Protection, as noted earlier, is a valuable resource within our province. They dedicate significant resources to educating the public on the myriad issues connected to exploitation of children.13 One such resource is a plain and simple explanation of the Canadian laws regarding when young people can (and cannot) consent to sexual activity. 13 For more on the Canadian Centre for Child Protection, please visit their website: https://www.protectchildren.ca/en/ 83 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story CHILD’S AGE Under 12 years old CAN CHILD CONSENT? NO; no person under 12 is able to consent to sexual activity. 12 or 13 years old SOMETIMES; only if the age difference is LESS THAN 2 years *. 14 or 15 years old SOMETIMES; only if the age difference is LESS THAN 5 years*. 16 or 17 years old YES; BUT there are exceptions*. 18 years old YES. *IMPORTANT NOTE: No child (person under 18 years of age) can legally consent to sexual activity with another person if the other person is in a position of trust or authority over the child, the child is dependent on the other person, or the relationship is otherwise exploitative. Source: Canadian Centre for Child Protection Service Delivery: Documentation The CFS Standards Manual s.1.7.1 Service Records (Government of Manitoba, 2009) requires that documentation facilitate the case management process.14 Throughout the CFS agency’s involvement with Angel and her family there was a lack of required documentation and file keeping was sparse. At certain points, it might have been plausible that the CFS agency made contact with the family, however, absent evidence of any work occurring, our office must conclude that the CFS agency was not involved and when involved, did not meet basic and minimum service standards that require proper documentation. For example, the file lacked information regarding CFS agency contact, family visit arrangements, planning, and progress of plans. It is unknown if this lack of information means that the CFS agency was not involved, or if there was involvement, but no documentation. As time progressed, the CFS agency files included more documentation; however, gaps remained. Without proper documentation, important information was lost, which is required to make informed decisions, regarding, assessments, case planning, and evaluation, and without documentation file history becomes entirely dependent on the memory recall of individual workers who may no longer be employed with the CFS agency. If the CFS agency did provide additional services which are not documented on their files, it would be even more concerning since that would mean that workers saw what was happening and repeatedly left Angel in risky situations. Families have a right to expect that when a system as large and powerful as CFS is involved, that workers are well-trained, are providing appropriate services, and that agencies are able to be held accountable 14 See: https://www.gov.mb.ca/fs/cfsmanual/1.7.1.html 84 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story for the decisions and interventions that can so significantly impact a family. One of the ways that agencies are accountable is in their record keeping (Government of Manitoba, 2009).15 A CFS agency file should be a complete record of service decisions, family support networks, service goals, and any known safety concerns. Documentation is not just a required part of CFS agency involvement in a family, but it is the living account of what decisions are being made, how those decisions are being made, what conditions and goals a family is aiming to achieve, and how progress is measured. A lack of proper documentation leaves no accountability trail and does not demonstrate that a CFS agency is fulfilling their legal mandate. Documentation is not optional and when agencies are not accounting for their interventions, it can make imposed conditions impossible for a family to achieve. Service Delivery: Frequency of Contact The provincial CFS Standards Manual 1.1.4 Service Provision (Government of Manitoba, 2009) addresses the frequency with which contact should be made with families. The case manager maintains contact with the family based on the level of risk to the life, health or well-being of children identified in the intake and assessment stage as follows: High Risk: There is face-to-face contact at least once a week. At least one of these contacts is made by the assigned case manager each month and a least one takes place in the family’s home. There is face-to-face contact with vulnerable children at least every two weeks Medium Risk: There is face-to-face contact with the family at least once every two weeks. At least one of these contacts each month is by the assigned case manager and at least one takes place in the family’s home. There is face-to-face contact with vulnerable children at least once every two weeks. Low Risk: There is face-to-face contact with the family at least once a month. At least one of these contacts is made by the assigned case manager every three months is by the assigned case manager and at least one takes place in the family’s home. There is face-to-face contact with vulnerable children at least once a month. No Apparent Risk: Services are based on need set out in the case management plan.16 15 See an extensive list of required Record Management Practices at https://gov.mb.ca/fs/cfsmanual/1.7.1.html#management 16 See: https://gov.mb.ca/fs/cfsmanual/1.1.4.html 85 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Frequency of contact with Angel while she was a child in care did not meet minimum provincial standards. Section 1.1.4 Service Provision (Government of Manitoba, 2009) details the frequency of contact agencies must have with children for whom they have legal guardianship: Frequency of Contact with Caregivers - When a child is in the care of the agency the case manager, in addition to maintaining contact with the family:  has face-to-face contact at least once a month with the child's caregiver(s)  has face-to-face contact at least once a month with the child in the child's place of residence  gathers information, records, photograph, and other memorabilia to create a life book of a child is likely to stay in care for more than one year including:  three month progress reports  information or records on critical life events such as birthdays, first (for example, tooth, steps, ride a bike, date) and school achievements  contact names17 In Angel’s experience, the frequency and nature of contact by the CFS agency with Angel and with her family was determined largely by complaints and crises, rather than maintaining contact as was required for conducting a collaborative assessment and planning process. For the periods when Angel was in the care of the CFS agency, two face-to-face contact visit with Angel were recorded (August 27, 2010 and June 17, 2015). Evaluation The final step in case management is to consider how successful the plan and service provision were in meeting the needs outlined in the assessment. This important area of service delivery is also clearly detailed in the provincial CFS Standards Manual in Section 1.1.5 Evaluation (Government of Manitoba, 2009): Effective evaluation requires regular opportunities for the family, children, community members and service providers to communicate with the case manager about the plan and the services provided and for the case manager to receive support to effectively manage the case. Opportunities are provided through phone calls, home visits, case conferences or other meetings, written reports and formal review. Evaluation enables the agency to identify both common concerns and successful methods that may be addressed at the community level. 17 See: https://gov.mb.ca/fs/cfsmanual/1.1.4.html#s3 86 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story The case management decisions at the evaluation stage are:  Is the plan being followed and are the standards being met?  Is the plan effective and are the needs of the person or family being met?  Is the level of service adequate and are the services meeting the needs of the family or child?  Are there significant changes in the situation such as a change to the level of risk to children to require a review?  Does the assessment need to be updated?  Is the case category still appropriate?  Can the case be closed?18 Not surprisingly, in Angel’s life, since the CFS agency did not conduct proper assessments, did not plan from a place of understanding the strengths and needs of the family, did not respond consistently to reports of abuse, and frequently did not document, they were unable to evaluate any progress being made. As such, CFS decisions were made based on the information in front of the agency on any given day and reflected no understanding of how each event and each experience was continuing to hold the family back from achieving success. Accountability Within the System: Following the Route of Legislation An element of the challenge regarding establishing standards and then ensuring all CFS work meets these standards at a minimum, lies not only in that the CFS manual is lengthy and onerous, but that when CFS workers begin working with families without having been trained in these minimum standards, it is unrealistic to expect that they will deliver services to families that meet these standards. The Manitoba CFS system has been partly devolved from a centrally controlled system (as seen in most other provinces whereby a government department is wholly responsible for delivering provincial child and family services), to a system unique to Manitoba where four culturally-based CFS Authorities receive their legal mandates from the provincial government to oversee their own agencies. This model is intended to be more responsive to community and cultural needs. Devolution of the CFS system in this province began with the proclamation in 2003 of The Child and Family Services Authorities Act. Since that time, families receiving CFS services in Manitoba have been able to receive CFS services from the CFS Authority that aligns with their cultural preference. Indeed, the CFS Authorities Act includes as a principle: WHEREAS the development and delivery of programs and services to First Nations, Metis and other Aboriginal people must respect their values, beliefs, customs and traditional communities 18 See: https://www.gov.mb.ca/fs/cfsmanual/1.1.5.html 87 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story and recognize the traditional role of women in making decisions affecting family and community.19 In our work around the province, we frequently observe (and hear from children and youth) that service is inconsistently delivered to families, depending on a number of factors. The minimum provincial service standards are intended to ensure that regardless of where a family is located in the province or which CFS agency or authority they are in contact with, service standards are similar, while also reflecting local context. When families are not receiving services that meet minimum standards of practice, The Child and Family Services Act (1985) and The Child and Families Authorities Act (2003) describe the lines of accountability and which entity is responsible for what element of service delivery. Brief Summary of Duties by Area of CFS System Structure Minister of Families: Duties including: administration of The Child and Family Services Act (CFSA), administrative oversight of the Director of Child Protection; delegating through regulations powers and duties from the Director to the Authorities; in consultation with the Authorities, passing regulations respecting any other matter the minister considers necessary or advisable for ensuring the appropriate delivery of CFS services. Child and Family Services Division (Director of Child Protection): The 4 CFS Authorities (Northern First Nations, Southern First Nations, Metis, General): Duties including: administering and enforcing the CFSA (with the Authorities); ensuring the development and establishment of standards of practice for service delivery; carrying out investigations and making enquiries into the welfare of any child; performing any such duties as may be prescribed by the CFSA or as may be required by the Minister. Duties partly include: administering and enforcing the CFSA (with the Director of Child Protection); administering and providing for the delivery of child and family services through its agencies; promoting safety and protecting children; advising the minister about CFS matters; developing culturally appropriate standards; ensuring standards are consistent with provincial minimum standards; ensuring agencies deliver services that meet minimum standards and ensure safety of children; allocating funding among agencies; ensuring development of appropriate placement resources, etc. CFS Agencies in Manitoba: Duties including: protecting children, delivering services that meet minimum provincial standards; working with other systems to resolve issues likely to place children at risk; investigating allegations a child may be in need of protection; providing family guidance and counselling; providing services to families that will help them care for their own children, providing care for children in care; providing other services and performing other duties under the CFSA or The Adoption Act; and conforming to direction given by the Authorities. 19 See: https://web2.gov.mb.ca/laws/statutes/ccsm/c090e.php 88 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Minimum provincial standards are not optional. They are required to be met so that families can be assured a minimum standard of care. As noted in the Phoenix Sinclair Inquiry (2014), “The Department [known now as The Child and Family Services Division] has the responsibility to develop foundational standards to ensure a level of consistency of practice across the province” (Volume 2, p. 373). And further, the final report of the inquiry noted, “A set of provincial foundational standards had been released to all agencies and the Authorities in January 2005. Their development is ongoing and the current standards are posted online...These standards apply across the system, both on and off reserve” (Volume 2, p. 374). Our office discussed the issue of minimum standards in our recent publication, Documenting the Decline: The Dangerous Space Between Good Intentions and Meaningful Interventions (“Documenting the Decline”) (Manitoba Advocate, 2018). As noted there, the Manitoba Advocate analysed 569 recommendations that have been made in previous child death investigations by our office since February 2009, when The Manitoba Advocate for Children and Youth (MACY) office was known as The Office of the Children’s Advocate. As noted in the table below, our office has made many recommendations related to concerns in the areas of: assessments (risk/family/child), planning, service delivery, service coordination, training, documentation, abuse investigations, and more. These are all areas covered by Core Competency basic training and described in minimum provincial service standards. In the previous nine years, the CFS system has reported that 462 (81%) of the 569 recommendations the Manitoba Advocate has made are “complete,” and yet many of the same issues persist throughout the province and within the same agencies and CFS authorities. CFS Recommendations by MACY (2009-2018) Recommendations Theme Area Made Case Management 173 Service Coordination 111 Training for CFS Workers 108 Accountability Safety/Risks to Child Placement Issues Abuse Investigations 82 61 39 34 Sub-Themes Assessment, Service Delivery, Case Planning, Evaluation Sharing of information between collaterals Enhanced Training for Frontline Staff, Minimum Service Standard Training for Agency Staff, Suicide Awareness Training Proper File Recording, Proper Supervision Suicidality Licensing Proper Response to Reports of Abuse In Documenting the Decline, the Advocate made a formal recommendation that the Department of Families clarify training expectations within the CFS system and “…prioritize the development of high quality, culturally appropriate, modernized, and accessible training on the minimum provincial service standards” that workers require in order to understand and consistently meet minimum service standards. With an understanding that establishing clear training expectations and training opportunities is a foundational element to overall system quality, the Advocate builds on that foundation. Quality 89 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story training and system knowledge will be limited in effectiveness in the absence of measures that galvanize accountability across the entire system. CFS workers have an obligation to deliver services that meet standards and supervisors have the responsibility to ensure their workers are meeting those expectations. As depicted in the table above titled “Brief Summary of Duties by Area of CFS System Structure,” the chain of accountability connects from the agency to the Authority, from the Authority and, ultimately, resides with the Minister of Families. RECOMMENDATION FOUR: Child and Family Services The Manitoba Advocate for Children and Youth recommends that the Minister of Families, through the Child and Family Services Division (CFSD), in collaboration with the four child and family services Authorities, (1) conduct an evidence-informed review and update of existing provincial service standards, and (2) establish province-wide measures of service accountability through a provincial quality assurance framework. Both the service standards and the quality assurance measures must be consistent throughout the province, culturally appropriate, and supported and enforced by the governing child and family services Authorities within their child and family services agencies. As per provincial legislation, quality assurance measures at the authority level must then be assessed and monitored by the Minister of Families. DETAILS: This province-wide quality assurance framework should include: • An evidence-informed review and update of existing Child and Family Service standards • That the updated standards reflect a requirement that service models being used in the CFS system move away from an apprehension model and toward service models that require meaningful engagement of family, extended family, and community, which is in the best interests of children. 90 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story FINDING FIVE: An addictions/substance misuse treatment strategy for sexually exploited/trafficked children, youth, and young adults in Manitoba is urgently needed. This is a critical part of the continuum of care that will save Manitobans money over the long term. With the benefit of hindsight, we believe that Angel’s death could have been prevented had she received services, particularly viable treatment options to help her with her compound trauma and addictions. As seen above, Angel’s actions were of a child who was repeatedly crying out for help to no avail. Angel is not alone. Indeed, there have been hundreds of other SEY who are in the same situation as Angel and several SEY in Manitoba who are – as you read this – at high risk of preventable deaths. Consider the following current examples of seven Manitoba youth: This youth, who is now 17 years old, was exploited since she was 13 years old within Manitoba and trafficked for the purpose of sexual exploitation out of province. At the age of 15 she was hospitalized over 15 times in 12 weeks, for she was heavily addicted to methamphetamine and at extreme risk for harm. Police and other supports continuously located this youth highly intoxicated on methamphetamine and requiring medical assistance on a number of occasions. She weighed less than 80lbs and began injected methamphetamine into her neck. She disclosed numerous sexual assaults and incidents of sexual exploitation during the periods of time that she was reported missing. Upon withdrawal, this youth presented with severe body pains, shakes, and mood swings causing her to seek out substances to avoid these symptoms. There were no equipped facilities in Manitoba to address her addictions. This youth is currently pregnant as a result of sexual exploitation and continues to struggle with methamphetamine use. She has not received the addictions treatment/support she urgently needs. This youth has used solvents and other substances since the age of 12 and has been the victim of numerous sexual assaults and ongoing sexual exploitation. This youth began to use methamphetamine in 2016 to the point of being in active psychosis, experiencing constant visual and auditory hallucinations as well as being totally detached from reality. This youth has a clinical team now attached to her and now has a diagnosis of schizophrenia. This youth, now 17 years old, has experienced ongoing victimization and trauma due to her being so vulnerable to offenders and her continued addiction. This youth did not have access to appropriate treatment and intervention to address her addiction and how will have lifelong impacts as a result. 91 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story This youth has been exploited since in her early teen years. At 16, she is heavily addicted to methamphetamine, and uses intravenously. This youth has cognitive challenges that are compounded with her substance use. There is concern of her going into active psychosis. She has disclosed being exploited in exchange for substances and is extremely vulnerable to continued exploitation and harm due to her disability. As this youth’s substance use has continued to increase, supports have witnessed her cognition and ability to process and understand significantly impacted. This youth is at extremely high risk of going missing and being exploiting, yet there are currently no treatment options to provide her with the help she urgently needs. Her understanding of addiction and how this impacts her is extremely limited due to her cognitive challenges, and there are no specialized resources or placement options that can maintain her and address her challenges. This youth will spend short periods of time in stabilization units; however, often goes missing upon discharge in order to use substances. A youth who died by suicide in 2016 at the age of 17 was sexually exploited and heavily addicted to alcohol, pills, cocaine, and numerous other substances. She died by suicide shortly before she was to testify against an offender who exploited her, her sister, as well as dozens of youth. The court process took almost two years before this youth was to testify causing re-traumatization and her continued substance use to cope with this. This youth would continue to seek alcohol and substances to avoid having to come off as she had severe withdrawal symptoms, including extreme physical pain, enuresis, and vomiting. The youth’s sister died by suicide in 2010 after being exploited by this same offender. This youth was heavily addicted and there were no viable treatment options to address her addiction and trauma from her sister’s death and her own exploitation. This youth was referred to receive services from a specialized program that works with exploited youth; however, she was not able to actively receive services from the program due to the program having a waitlist. A female youth who is extremely gang entrenched and believed to be exploited by gang members has been provided with methamphetamine and pills by these individuals. This youth, who is 16 years of age, often goes missing for long periods of time (e.g. four weeks at a time). When located, she is often severely malnourished, has significant weight loss, and has visible track marks from intravenous substance use. This youth has made positive connections with supports at her placement; however, her addiction continues to pull her away from them. This youth, who is often easily engaged and bright, can become violent and aggressive when under the influence and coming off of substances. She has made disclosures of owing money to gang members and having to work off this debt. This youth is resistant to addictions treatment and there are no viable options for the CFS agency involved to explore in order to provide her with the urgent help she needs. 92 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story A youth who has been sexually exploited and using substances since she was 11 years old has been reported missing on numerous occasions. She has disclosed that she was heavily addicted to methamphetamine and crack and injecting intravenously. This youth has been located on many occasions in areas known to be part of the sex trade, inside vehicles belonging to adult males, and removed from homes of adult males suspected to be exploiting her. She has disclosed spending time with known drug dealers, sexual assaults, and exploitation. She spent several months in a specialized facility to address mental health challenges; however, upon discharge she began using substances again and is being exploited as her co-occurring issues were not addressed. This youth is currently 16 and continues to go missing for long periods of time, is using crack, and is being exploited by offenders. This youth, now 16, entered the CFS system at the age of nine after witnessing and being a victim of horrific neglect and abuse. Since the age of 12, she has had numerous incidences of self-harm, suicide ideation, and serious suicide attempts where she required emergency medical assistance and evaluation. This youth became involved in the justice system at the age of 13 when she began to act-out her pain and trauma. She is sexually exploited and is highly addicted to methamphetamine and other drugs of an unknown nature. She also lives with a very serious health diagnosis for which she is non-compliant with medications. This youth remains pre-contemplative regarding therapy and addiction treatment. Coupled with the fact that she is not med-compliant, continues to be re-traumatized by sexual exploitation and her use of methamphetamine continues to increase, she is at imminent risk of death or serious harm. There are no facilities within Manitoba that can address her addictions, nor are there any long-term resources willing to work with this youth. Methamphetamine Use is Increasing Among Sexually Exploited Youth The case scenarios above and data below reveal that methamphetamine use is increasing among sexually exploited, high risk youth. It is important that those providing services to this demographic acknowledge the unique challenges that accompany this, including withdrawal symptoms for up to 90 days, altered personality, exacerbation of pre-existing mental illness, drug-related apathy that is exploited by those who sexually abuse them, drug-related psychosis, and the risk of permanent brain damage. 93 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Meth Use: SEY on StreetReach High Risk Victim, Assessment Consideration, and Monitored List N=197 59.52% 21.74% 22.22% 2011-2012 2012-2013 41.03% 45.31% 2013-2014 2014-2015 2015-2016 Source: Manitoba Families, unpublished(a), p. 57 There has been a significant rise in methamphetamine and fentanyl use by SEY in Manitoba. Yet, resources for SEY in the province have been funded solely to address sexual exploitation in isolation of the reality that it is manifesting with addictions, among other co-occurring variables. Further, the province does not have a mental health and substance treatment strategy for these youth, translating in the inability to respond to this crisis. Since 2012, Manitoba has seen a major increase in methamphetamine and intravenous drug use among SEY (Manitoba Families, unpublished(a), p. 57). Six years later, there remains a lack of viable treatment options for these children and youth with life-threatening addictions. Manitoba Lacks Viable Treatment Options for Children and Youth with Life-Threatening Addictions The situation for youth with addictions in Manitoba, including SEY like Angel and those whose scenarios are above, has reached a crisis point. On September 21, 2018, the Advocate released a statement of concern on the state of youth mental health and addiction services in Manitoba. It notes that 10.8% of children aged 6-12 years have experienced a significant mental health or addictions issue in this province. Further, for youth aged 13-19 years this rate increases to 17%. Given the prevalence of mental illness and addiction issues among our young people, including SEY, this means there can be no one who is untouched by this crisis. All of us, as parents, grandparents, and community leaders, have a personal stake in doing better by our children and our youth. (Manitoba Advocate for Children and Youth, 2018, p. 1) Accidental drug-related deaths and overdoses like that of Angel are skyrocketing. The province of Manitoba’s Virgo report (2018) speaks to this crisis in the area of mental health and addiction service delivery for children, youth, and young adults in the province. Our office agrees with the Virgo team’s assessment that our youth mental health and addictions system is marked by inadequate funding for services, insufficient early intervention services, and the need for 94 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story universal prevention resources and supports for all children and youth. This is particularly the case for the hundreds of SEY per year, including those whose cases are summarized above, who are struggling with life-threatening addictions connected to compounding trauma for which they do not have the support or treatment they need. On October 19, 2018, our office made a recommendation regarding the need for a youth addiction strategy in Documenting the Decline: The Dangerous Space Between Good Intentions and Meaningful Interventions (“Documenting the Decline”) (Manitoba Advocate, 2018, p. 95). This recommendation reads as follows: The Manitoba Advocate for Children and Youth recommends that the Department of Health, Seniors and Active Living, together with front-line addiction service providers in Manitoba, Healthy Child Manitoba, Indigenous communities, and subject matter experts on addictions, immediately respond to the lack of effective substance use treatment services for youth by prioritizing the development and implementation of a youth addiction action strategy. This strategy should be based on best practice evidence with the objective of ensuring that children and youth across Manitoba can exercise their right to the highest attainable standard of health. Details:  That the Department of Health, Seniors and Active Living, go beyond the Virgo analysis and conduct a service inventory of all child and youth addiction services in Manitoba, their locations, target populations, philosophies, eligibility criteria, utilization rates, and occupancy rates.  That the Department of Health, Seniors and Active Living expand upon the Virgo analysis to evaluate existing gaps in substance use treatment and addiction services available to children and youth, including recommendations as to how existing services could be repurposed.  That the Manitoba’s Mental Health and Addictions Strategy developed by the Department of Health, Seniors and Active Living include a plan that ensures implementation of evidence-informed family-centred substance use and addiction programs.  That the Department of Health, Seniors and Active Living oversee regular performance monitoring and program evaluations to ensure that all publicly-funded and provincially mandated agencies are accountable to provide evidence-informed addiction services and programs for children and youth.  That all provincially-funded addiction service providers working with children and youth implement policies and procedures for ongoing training on the identification and reporting of cases where a child is in need of protection as outlined in The Child and Family Services Act. 95 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Once again, we urge the province to create a youth mental health and addictions strategy. It follows that this strategy should include provisions for sexually exploited children and youth. FINDING SIX: At present, there are no viable treatment options within Manitoba for sexually exploited children and youth presenting with life-threatening addictions. As noted above, substance misuse and the injection of drugs intravenously by children and youth in Manitoba has increased exponentially. On a daily basis, children require emergency medical treatment for near-fatal overdoses and drug related medical crises from extreme drug misuse. Angel’s story and the examples above of child-specific incidents reveal that children who are struggling with addictions (often as a result of trauma) require immediate intervention to mitigate the extreme risk they face. While the number of children abusing substances and injecting methamphetamine is increasing at an alarming rate, there are no involuntary, safe and secure, or long-term treatment options in Manitoba to address addictions and exploitation issues. At present, many youth in Manitoba, including SEY like Angel, who are addicted to drugs or substances are not voluntarily willing or able to enter treatment. In Angel’s case, while in PY1, a thorough assessment was conducted which informed a discharge plan which was developed by health professionals. Upon her discharge from PY1, her foster parent and Angel’s CFS worker were given a list of mental health and other support services to follow-up on. Although our office was informed by Manitoba Health that a referral to the Manitoba Adolescent Treatment Centre (MATC) would be common, we confirmed that no such referral was ever made. Angel’s case is reflective of the fragmented and disconnected nature of Manitoba’s child and youth addiction and mental health services system, which includes private, public, and federal entities. Manitobans need to know where to turn to get addiction and mental health services. However, parents like Angel’s mother and others who contact our office continue to share the belief that when they seek to access these services on their own, their child will be placed on a waitlist. There is the perception of more availability of services and treatment within the CFS system in terms of specialization, cost, and availability of services, including therapy in the areas of intergenerational trauma and child psychology. As such, parents like Angel’s mother feel they have to place their children in care voluntarily in order to access mental health and addiction services their children require. Of further concern is the fact that existing addictions resource/treatment options available to children and youth in Manitoba often present with systemic challenges, resulting in children and youth not being 96 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story able to access or benefit from them. Current legislation also creates barriers to obtaining warrants or securing youth for treatment for the length of their withdrawal symptoms (e.g. up to 90 days for meth). This results in SEY leaving treatment prematurely and, as a result of their addiction, returning to their exploiters who provide them with meth and other substances. At present, Manitoba’s Youth Addiction Stabilization Unit (YASU) offers involuntary treatment for a maximum of seven days. However, the admission process requires that the CFS agency or guardian seek and obtain a warrant for treatment. This process also requires the child or youth to be in placement, but sexually exploited and addicted children are chronically missing and/or have no placement, so guardians are often unable to obtain a warrant for involuntary treatment. In addition, children and youth can only access YASU once within a 30-day period when, as noted, withdrawal symptoms related to meth can last up to 90 days. YASU also offers voluntary admittance into a seven-day program. However, here too gaining entry and access often presents a challenge, as intake is only offered from Monday – Friday, 8:30 a.m. – 4:30 p.m. Our office is aware of cases of children being turned away due to the day and/or time that they are presenting voluntarily. It is very concerning that children and youth are being turned away when they are ready and willing to receive treatment for life-threatening addictions. Additionally, it is difficult to understand how YASU, funded by the province at $2.8 million per year, can have an occupancy rate of 22% to 41% during the current methamphetamine crisis youth in Manitoba are experiencing (Virgo, 2018, p. 166).On average, youth stay in YASU for between 4.8 and 5.7 days (Virgo, 2018, p. 168). The Addictions Foundation of Manitoba (AFM) residential treatment centre for youth is a 14-bed facility known as Compass, which operates an eight-week long program that runs 11 months of the year. One month per year it is shut down for staff holidays and training. Compass was funded at $1.6 million in 2016-2017. During this period, it reported an occupancy rate of 27%, with youth completing, on average, 33 out of a potential of 56 days of programming (VIRGO, p. 166, 168). Similarly, the Northern Regional Health Authority’s Hope North program in Thompson, which offers a 4-bed crisis unit and two beds for youth addictions stabilization, is also being underutilized (Virgo, p. 156). More recently, AFM has sought to increase occupancy at Compass. While the occupancy rate was 27% last year, our understanding from AFM is that the average occupancy rate of Compass for this current fiscal year is 57%. Notwithstanding, the question remains as to whether SEY have successfully completed this program, as it has been reported to our office that the majority of SEY do not complete more than a 97 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story few days. This program does not appear to be working or meeting the needs of SEY who are struggling with life-threatening addictions. Emerging research on involuntary treatment suggests safe and secure treatment ought to be part of the continuum of options for children and youth struggling with addictions. This research also reveals that “secure facilities” do not need to be institutions. They can be secured via adequate staffing, geographic locations, and be holistic and culturally-based home-like settings. RECOMMENDATION FIVE: Mental Health & Addiction The Manitoba Advocate for Children and Youth recommends that the Department of Health, Seniors and Active Living and Department of Families, in collaboration with the Addictions Foundation of Manitoba, (1) review and reform the province’s treatment programs for children and youth and (2) create safe and secure facilities for youth in Manitoba who are sexually exploited and harmfully involved in substance misuse. DETAILS: This should  Involve community organizations;  Address the limitations, barriers and occupancy rate concerns of existing resources (e.g. Compass, YASU);  Include a harm reduction policy specific to children and youth;  Recognize that “secure facilities” do not need to be institutions, but can be secured via adequate staffing, geographic locations, and can further be holistic and culturally-based home-like settings;  Involve youth, experiential, and Indigenous stakeholders;  Address accessibility challenges related to addiction and mental health treatment services1;  Be informed by a scan of jurisdictions who successfully incorporate short and longterm safe and secure settings in their continuum of care models for youth who are sexually exploited; and  Be included in the Provincial Mental Health and Addictions Strategy. 98 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Early Intervention and Prevention are Cost-Effective On December 7, 2018 (Government of Manitoba News Release, 2018), the province announced a federal-provincial agreement to fund “flexible length withdrawal management beds for people with methamphetamine use disorder”. To our office’s dismay, this bi-lateral agreement providing approximately $4.2 million in matching funding between now and 2023 is for adults – it does not include any funding or beds for youth like Angel and those in the seven scenarios listed above with no viable treatment options for life-threatening addictions. The lack of early intervention and prevention for youth in the area of addiction and mental health is alarming. It also does not make sense in terms of value for money. The fiscal costs of child sexual exploitation are concerning, but more concerning are the personal costs, to the children, their families, and society. These of course cannot be measured by quantitative methods, as there cannot ever be a value placed on one child’s abuse. Evidence over the last 30 years has demonstrated the need to prevent and intervene early with respect to child sexual exploitation. The majority of scholars who have studied harm reduction have discussed this as being the most effective measure to reduce and eliminate sexual exploitation from our society. Further research has discussed children and youth who are in care of the CFS system being at a high risk for offenders to target due to not having the same protections as children and youth who reside with their families and communities. This special report has demonstrated several instances where there was a lack of awareness and lack of early intervention and prevention efforts used to protect Angel. Angel is one of many children Manitoba has lost as a result of sexual exploitation and drug/alcohol misuse. It is clear that early intervention and prevention makes sense. The cost to fund prevention initiatives for youth who are sexually exploited are substantively less than lifetime costs associated with health care, the justice system/corrections, housing and community support services. A 2005 study analysed the incremental fiscal costs on society’s institutions over a life cycle in the event that a youth is sexually exploited in the sex trade in Manitoba. It found that, “Although for many youth, involvement in the sex trade is a temporary life experience (average 10.1 years in this study) it results in a permanent impact on government and community support services and a lifelong impact on the individuals involved” (Buckle, 2005, p. 5). It was estimated that for each youth who becomes sexually exploited the direct fiscal cost is $236,195 dollars. When looking more broadly, the societal and fiscal costs total $446,026 per child over their lifetime (Buckle, 2005). 99 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story (Source: Buckle, 2005) Extrapolating from this report and the table above 13 years later after their release, it follows that the magnitude of this permanent impact continues to grow and compound in economic and social terms, including utilization of resources and lifetime earning losses for these youth. For instance, if we apply this to StreetReach’s annual report data from 2017, which does not purport to represent all of the cases of SEY per year, a very conservative fiscal estimate would total $75,818,595 million dollars ($236,195 x 321 children). If taking a global calculation and including the societal and fiscal costs, the estimated total would be $143,174,346 million dollars ($446,026 x 321 children) (Manitoba Families, unpublished(b)). Preventing children from becoming sexually exploited by being aware of the indicators of sexual exploitation and taking necessary measures to ensure they have adequate resources to divert them from the sex trade is the responsibility of all government funded resources. That said, policies that are only geared towards intervention (often when SEY are entrenched) are not fiscally responsible to children and their families. Early prevention and intervention can potentially place children and youth on a different life trajectory and avoid future costs to publically-funded services. Victims who continue to be trafficked from youth to adulthood are more likely to rely heavily on various publically-funded supports such as social assistance, abused women’s shelters, social housing, 100 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story emergency health services, and Victim Services. Furthermore, and much more importantly, taking an upstream approach is the right direction to take. It is important that we take guidance from 30 years of research and implement more prevention strategies to, first and foremost, prevent children from becoming sexually exploited in the first place. Once Angel became exploited, she should have been able to access a number of publically funded resources. However, many of the policies within these resources were not developed with an SEY lens. As a result, SEY like Angel continue to be systemically marginalized within publicly funded programs that should be able to meet the needs of all children. Angel was likely sexually exploited by numerous men since she was 11 years old, but quite possibly from 7 years old. The indicators that Angel presented with should have sent red flags up to the service providers, police, and educators that this child was interacting with. Unfortunately, none of them were able to identify the issue of sexual exploitation, and she continued to be sexually abused for years. Many children who are being abused in this manner turn to drugs and alcohol to cope with the constant trauma and horrific sexual abuse. Several studies have also found that children will “runaway” or leave safe places so that they can obtain substances in order to cope with being sexually exploited (Brawn & Roe-Sepowitz, 2008; Dalley, 2010; Melrose, 2004; Saewyc & Edinburgh, 2010; Thomson, Hirshberg, Valila, & Howley, 2011). Once a child has been sexually exploited and drug/alcohol use becomes dependent, due to the high risks associated with both issues, an immediate systemic response is needed to address co-occurring complex issues. Angel meets the description of repetitive abuse as per findings in research on sexually exploited children and youth (Cloitre, Stolbach, Herman, Kolk, Pynoos, Wang & Petkova, 2009; Lloyd, 2011; Hardy, Compton & McPhatter, 2013). These studies reveal that children develop PTSD from constant sexual abuse by different men. Angel was taken to mental health settings on numerous occasions, only to be sent back to a foster placement that was not equipped to deal with her mental health struggles. It would appear that the mental health system also did not identify the unique mental stressors for this child, nor did they intervene appropriately to ensure the provision of adequate resources. This is quite commonplace for sexually exploited children and youth. Very often, their behaviour, in reaction to the abuse, is what is identified as the issue, and the trauma that is causing the behaviour is not identified. This special report reveals that the mental health resources from which Angel desperately attempted to seek help need further awareness training to identify and provide adequate resources to assist sexually exploited children and youth. 101 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story As noted, in addition to the 22%-41% vacancy rate, a number of SEY are unable to access or are denied access to YASU as a treatment resource. There does not appear to be clear policy regarding access to this resource. Clear policies are urgently needed for accessing all treatment resources in this province, and SEY need to be able to have equal or more access to these resources. The social, fiscal and, more importantly, human costs of them not being able to access them are significant. Moreover, the Advocate stresses the need for policies and procedures to be child-centred to ensure treatment resources are meeting the evolving needs of children and youth. Without an appropriate treatment resource to respond to these children’s needs, nor a continuum of mental health and addiction treatment service options that meets SEY where they are at, social and fiscal costs will continue to grow year after year, with many more children being horribly abused, and it is highly probable that further tragedies will occur. As has been emphasized, short sighted reactive policies are not meeting the needs of SEY, and 30 years of data on this population indicates that approximately 70% of children who are sexually exploited are in the care or have had contact with the CFS system. Service providers in Manitoba need to be responsive to these families and their children, who are ultimately also our children, as we all have a responsibility to ensure that all children are safe. Although Angel was in a single placement for over 3 years, the sexual exploitation was still occurring and her dependence on drugs became more and more harmful and high risk. It is unfortunate, that these two issues that were the most prominent and highest risk went unaddressed. They are also the two issues directly linked to her death. RECOMMENDATION SIX: Mental Health & Addiction The Manitoba Advocate for Children and Youth recommends that the Department of Health, Seniors and Active Living, in collaboration with the Addictions Foundation of Manitoba and other stakeholders, amend The Youth Drug Stabilization (Support for Parents) Act so that longer warrants or successive warrants are possible to ensure children and youth get the medically supported withdrawal management services they need based on evidence-informed treatment best practices for addictions (e.g. methamphetamine, alcohol, opioids). DETAILS: Work to this effect should:  Be overseen by an existing inter-departmental working group such as the Deputy Ministers of Health and Social Policy and Priorities (DMHSPP) committee/Healthy Child Deputy Ministers’ Committee (HCDMC); and  Be guided by evidence-informed best practices and knowledge in the areas of supported withdrawal management, addiction and mental health assessments, and accessibility of treatment services for children and youth. 102 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story With the proclamation of the Advocate’s new mandate provided by the The Advocate for Children and Youth Act (ACYA), the Manitoba Advocate is empowered to monitor and report publicly on the level of compliance with recommendations made by the Advocate. Our new mandate includes child and family services, adoption, disabilities, education, mental health, addiction, victim, and youth justice services. Our office is also committed to improving public awareness and opportunities for public education. To that end, the Advocate has initiated processes whereby systems, which receive recommendations for change, will be required to report their progress to the Advocate every six months. Those updates will be analysed by our office and this analysis will be shared publicly so that Manitobans can further monitor improvements in publicly funded, child-serving systems. 103 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story When my office conducts an investigation of the death of a child, as we have in Angel’s case, it can often take several months to years to move from initial receipt of the official death notification, to the closing of our file. In this case, members of my team have been gathering data, reviewing files, waiting on the conclusion of criminal proceedings, interviewing, analysing information, writing, and editing for more than three years. After so long a time it can be a challenge to decide when a report like this is ready for the public to view. Our commitment centres around the rights, views, and needs of the child who has died, and we know that the more we can uncover and gather about the life of the child, the more we will be able to honour them as we attempt to tell their story to the world. We know that we risk losing casual readers by creating reports of this length and depth, and while it is our goal in future special reports to offer more summarized findings to engage a wider audience, I also have other goals in sharing these stories. For many years, the work of the Advocate’s office was largely hidden from view. Under the new Advocate for Children and Youth Act we can now share much more of what we hear and see respecting the lives of young people across the province. We hold this delicate responsibility with reverence and it is my intention to demonstrate the child-centred, rights-based, and independent position of this office through all of our work, including in these special reports. My goals are to honour the legacy and memory of the child and to make evidence-informed recommendations that can transform how public services meet the needs of young people and their families. We all deserve to live in a province that is responsive to our changing needs and where publicly funded services are informed by subject-matter experts and delivered by those with high levels of knowledge, skill, and compassion. The six recommendations I make today are the result of a thorough investigation, calculated analysis, and collaborative discussions with many levels of the public service, provincial government, and Indigenous political leaders and governance systems. When implemented, they carry the likelihood of making comprehensive improvements in the ways young people are able to grow and thrive in Manitoba. As citizens of the province, each of you can help these objectives be realized by sharing Angel’s story and calling on public systems to move rapidly in response to the recommendations made herein to improve the lives of children and youth. In these ways, Angel’s name will be remembered and her preventable death will stand as a reminder that we can decide to walk together towards a better future that hears, includes, values, and protects all children, youth, and young adults. Respectfully submitted, Daphne Penrose, MSW, RSW Manitoba Advocate for Children and Youth 104 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story FINDING ONE: Like Angel, as a result of preventable adverse childhood experiences, children and youth across Manitoba continue to experience ongoing levels of compounding trauma that are now reaching crisis proportions. This trauma crisis manifests in many forms for children and youth, including addiction, mental illness, sexual exploitation, and preventable manners of early death. RECOMMENDATION ONE: Adverse Childhood Experiences The Manitoba Advocate for Children and Youth recommends that Manitoba Education and Training, Manitoba Families, Manitoba Justice, and Manitoba Health, Seniors and Active Living engage with experts in childhood trauma and Adverse Childhood Experiences (ACEs) in order to develop a trauma prevention and response plan of action to (a) educate service providers and the public on ACEs, and (b) create appropriate, accessible immediate and long-term evidence-informed interventions to address the trauma crisis that is ongoing in Manitoba. FINDING TWO: The province of Manitoba’s sexual exploitation strategy has neither a multi-disciplinary continuum of care, nor adequate resources to ensure early intervention and appropriate evidence-informed responses to cooccurring challenges for youth like Angel who are sexually exploited (e.g. experiencing sexual exploitation and abuse, mental illness, cognitive vulnerabilities, or addictions). RECOMMENDATION TWO: Sexually Exploited Youth The Manitoba Advocate for Children and Youth recommends that the Department of Families, in collaboration with Manitoba Education and Training, Manitoba Justice, and Manitoba Health, Seniors and Active Living, in consultation with Manitoba Status of Women, Indigenous and Northern Relations, the Winnipeg Police Service and the Royal Canadian Mounted Police, (1) expand StreetReach, Winnipeg Outreach Network (WON), and culturally appropriate services in First Nations and rural and remote communities; and (2) independently evaluate and then update Tracia’s Trust: Manitoba’s Sexual Exploitation Strategy. FINDING THREE: More needs to be done to raise public awareness about the ongoing demand for purchasing sex from minors and the relentless sexual exploitation of children and youth in Manitoba. RECOMMENDATION THREE: Sexually Exploited Youth The Manitoba Advocate for Children and Youth recommends that Communication Services Manitoba, Manitoba Education and Training, Manitoba Families, Manitoba Justice, Manitoba Health, Seniors and Active Living, Manitoba Status of Women, and Manitoba Indigenous and Northern Relations collaborate with youth advisory groups, the Canadian Centre for Child Protection, Winnipeg Police Service, Royal Canadian Mounted Police, Indigenous and community organizations, and the Manitoba Advocate for Children and Youth to carry out ongoing public education via awareness campaigns that (a) denounce the sexual exploitation of children and youth and (b) raise awareness about the ongoing demand for purchasing sex and/or sexually exploiting children and youth in Manitoba. 105 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story FINDING FOUR: Provisions within The Child and Family Services Act were not met regarding safety, security, well-being of Angel, or her best interests. Child and family services minimum required service standards were also not met in the areas of: assessment, case planning, service delivery, and evaluation. Failure to achieve minimum service standards is seen too-commonly in the provincial child and family services system. Accountability in service improvements is immediately required. RECOMMENDATION FOUR: Child and Family Services The Manitoba Advocate for Children and Youth recommends that the Minister of Families, through the Child and Family Services Division (CFSD), in collaboration with the four child and family services Authorities, (1) conduct an evidence-informed review and update of existing provincial service standards, and (2) establish province-wide measures of service accountability through a provincial quality assurance framework. Both the service standards and the quality assurance measures must be consistent throughout the province, culturally appropriate, and supported and enforced by the governing child and family services Authorities within their child and family services agencies. As per provincial legislation, quality assurance measures at the authority level must then be assessed and monitored by the Minister of Families. FINDING FIVE: An addictions/substance misuse treatment strategy for sexually exploited/trafficked children, youth, and young adults in Manitoba is urgently needed. This is a critical part of the continuum of care that will save Manitobans money over the long term. FINDING SIX: At present, there are no viable treatment options within Manitoba for sexually exploited children and youth presenting with life-threatening addictions. RECOMMENDATION FIVE: Mental Health & Addictions The Manitoba Advocate for Children and Youth recommends that the Department of Health, Seniors and Active Living and Department of Families, in collaboration with the Addictions Foundation of Manitoba, (1) review and reform the province’s treatment programs for children and youth and (2) create safe and secure facilities for youth in Manitoba who are sexually exploited and harmfully involved in substance misuse. RECOMMENDATION SIX: Mental Health & Addictions The Manitoba Advocate for Children and Youth recommends that the Department of Health, Seniors and Active Living, in collaboration with the Addictions Foundation of Manitoba and other stakeholders, amend The Youth Drug Stabilization (Support for Parents) Act so that longer warrants or successive warrants are possible to ensure children and youth get the medically supported withdrawal management services they need based on evidence-informed treatment best practices for addictions (e.g. methamphetamine, alcohol, opioids). 106 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story CHILD AND FAMILY SERVICES INVOLVEMENT APPREHENSION 1 (November 1, 1999) November 1, 1999 Placement #1 Winnipeg November 22, 1999 Returned to Parent Winnipeg March 17, 2000 Placement #2 Winnipeg March 21, 2000 Returned to Parent Winnipeg May 13, 2000 Placement #3 Winnipeg May 18, 2000 Placement #4 Winnipeg August 25, 2000 Placement #5 Winnipeg September 26, 2000 Returned to Parent Winnipeg APPREHENSION 2 (March 17, 2000) APPREHENSION 3 (May 13, 2000) SUPERVISORY ORDER (October 13, 2000 – April 13, 2001) APPREHENSION 4 (May 14, 2001) May 14, 2001 Placement #6 Community #1 May 16, 2001 Placement #7 Community #1 May 26, 2001 Placement #8 (Kinship) Community #1 June 6, 2001 Returned to Parent Thompson July 24, 2002 Placement #9 Community #3 July 30, 2002 Returned to Parent Community #3 August 30, 2002 Placement #10 Community #3 September 1, 2002 Placement #11 Community #3 September 5, 2002 Returned to Parent Community #3 September 28, 2002 Placement #12 Community #3 September 29, 2002 Placement #13 Community #3 October 3, 2002 Placement #14 Community #3 October 17, 2002 Returned to Parent Community #3 February 20, 2003 Placement #15 (same as #14) Community #3 February 25, 2003 Returned to Parent Community #3 Placement #16 Community #3 APPREHENSION 5 (July 24, 2002) DISCHARGED (January 7, 2003) APPREHENSION 6 (February 20, 2003) DISCHARGED (February 25, 2003) APPREHENSION 7 (May 10, 2003) May 10, 2003 107 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story May 12, 2003 Placement #17 Community #3 May 13, 2003 Placement #18 (same as #16) Community #3 May 14, 2003 Returned to Parent Community #3 June 5, 2003 Placement #19 Community #3 June 22, 2003 Placement #20 Community #3 June 23, 2003 Placement #21 Community #3 June 26, 2003 Placement #22 Community #3 July 9, 2003 Placement #23 (Kinship) Community #1 August 7, 2003 Returned to Parent Community #1 March 24, 2004 Placement #24 Community #1 March 30, 2004 Placement #25 Community #1 July 6, 2004 Placement #26 Community #1 DISCHARGED (May 14, 2003) APPREHENSION 8 (June 5, 2003) DISCHARGED (August 7, 2003) APPREHENSION 9 (March 24, 2004) 3 MONTH TEMPORARY ORDER (September 13, 2004) 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (December 13, 2004) 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (March 13, 2005) 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (June 13, 2005) 3 MONTH VOLUNTARY PLACEMENT AGREEMENT (September 13, 2005) DISCHARGED (November 1, 2005) APPREHENSION 10 (March 30, 2006) March 30, 2006 Returned to Parent Community #1 6 MONTH ORDER OF SUPERVISION (May 18, 2006) DISCHARGED (November 18, 2006) APPREHENSION 11 (February 4, 2007) February 4, 2007 Placement #27 (Kinship) Community #1 February 6, 2007 Returned to Parent Community #1 April 24, 2007 Placement #28 (Kinship) Community #1 May 7, 2007 Returned to Parent Community #1 DISCHARGED (February 6, 2007) APPREHENSION 12 (April 24, 2007) DISCHARGED (May 7, 2007) 1 MONTH VOLUNTARY PLACEMENT AGREEMENT (May 25, 2007) May 25, 2007 Placement #29 (Kinship) Community #1 June 20, 2007 Returned to Parent Community #1 108 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story DISCHARGED (June 20, 2007) APPREHENSION 13 (September 2, 2009) 6 MONTH TEMPORARY ORDER (September 24, 2009 – March 23, 2010) September 6, 2009 Placement #30 Thompson September 7, 2009 Placement #31 Community #6 March 26, 2010 Returned to Parent Community #1 August 5, 2010 Placement #32 Winnipeg August 16, 2010 Placement #33 Winnipeg August 23, 2010 Placement #34 Winnipeg August 27, 2010 Placement #35 Winnipeg August 27, 2010 Placement #36 Community #4 May 18, 2013 Placement #37 Winnipeg June 3, 2013 Placement #38 Community #4 DISCHARGED (March 26, 2010) APPREHENSION 14 (August 5, 2010) 1 YEAR TEMPORARY ORDER (December 23, 2010) PETITION FILED FOR FURTHER ORDER (December 23, 2011) 1 YEAR TEMPORARY ORDER (February 23, 2012) PETITION FILED FOR FURTHER ORDER (February 23, 2013) PERMANENT ORDER OF GUARDIANSHIP GRANTED (December 8, 2013) January 14, 2014 Placement #39 Winnipeg January 17, 2014 Placement #40 Community #5 February 19, 2014 Placement #41 Winnipeg February 24, 2014 Placement #42 Winnipeg February 27, 2014 Placement #43 Winnipeg April 18, 2014 Placement #44 Winnipeg April 22, 2014 Placement #45 Winnipeg May 8, 2014 Placement #46 Community #4 109 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story ACEs – Adverse Childhood Experiences ADHD – Attention Deficit Hyperactivity Disorder AFM – Addictions Foundation of Manitoba CSE – Child Sexual Exploitation FASD – Fetal Alcohol Spectrum Disorder IEP – Individualized Education Plan Northern Authority – First Nations of Northern Manitoba Child and Family Services Authority SEY – Sexually Exploited Youth RCMP – Royal Canadian Mounted Police YASU – Youth Addictions Stabilization Unit VSS – Victim Support Services WPS – Winnipeg Police Service 110 Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Special Report Section 31 of The Advocate for Children and Youth Act states the following: 31(1) In order to improve the effectiveness and responsiveness of designated services, the Advocate may publish special reports. 31(2) Subject to section 32 (limits on disclosure of personal information), a special report may (a) Include recommendations for (i) A minister responsible for the provision of a designated service, and (ii) Any public body or other person providing a designated service that the Advocate considers appropriate; (b) Refer to and comment on any matter the Advocate has reviewed or investigated under Part 4; and (c) Include information the Advocate considers necessary about any matter for which the Advocate has responsibility under this Act. The purpose of this special report is to examine the services provided to the child and his/her family and to identify ways in which those services may be improved to enhance the safety and well-being of children. The special report is intended to give voice to the experience of the child or young adult who has died. As such, it is conducted “through the eyes of the child,” that is, with a primary focus on the needs of the child or young adult. In carrying out this investigation, the Special Investigator is authorized to examine agency records and to make necessary confidential copies as required; to interview agency staff, service recipients and other service providers; and to exercise any other investigative powers under The Advocate for Children and Youth Act, section 25, subsection 26(1), and subsection 26(2). The report will include factual information relevant to the events preceding the death of the child, youth, or young adult, and make recommendations. As required in subsection 27(4) of The Advocate for Children and Youth Act, the Manitoba Advocate must deliver a confidential report under the following circumstances: Persons given report 27(4) A copy of the report must be given to (a) the minister responsible for the provision of a reviewable service that is a subject of the investigation; (b) any public body or other person that is a subject of recommendations in the report; (c) if the report makes recommendations for a child and family services agency, its mandating authority under The Child and Family Services Act; (d) if the report makes recommendations for a public body or other person funded by a regional health authority, that authority; and (e) the chief medical examiner if the report concerns the death of a child or young adult. 111 Youth Drug Stabilization (Support for Parents) Act Information for Parents In Manitoba, the Youth Drug Stabilization (Support for Parents) Act came into effect Nov. 1, 2006. WHAT YOU NEED TO KNOW 1 Youth Drug Stabilization Act You probably reached for this fact sheet because you have a serious concern about your son or daughter (or a young person who lives with you) who is involved in substance abuse. You want to get them the help they need, but they are unwilling. You may feel that your only choice is to get them help, even if they donʼt want it. The Youth Drug Stabilization (Support for Parents) Act provides a way to access involuntary detention and short-term stabilization for young Manitobans under 18 years of age. However, the act is intended as a last resort, when other measures have been unsuccessful and where a youth is causing serious self-harm through severe, persistent substance abuse. The purpose of the stabilization period is to provide a safe, secure environment to engage the youth and develop a treatment plan that he or she will follow after discharge. This fact sheet will help you determine if you should apply under the act for an apprehension order. It outlines what you need to do before you take this step and the steps that you need to follow if you feel that involuntary stabilization is the only option. 2 Before You Begin You must first ask yourself a few questions about the young personʼs substance use. Is this an occasional event or is it a severe, recurring pattern that has continued for a long time? Does he or she appear agitated or worn down when not taking the substance? Does your son or daughter devote a large amount of time or energy to getting the drug? Is the young person continuing to use even though it is causing physical or emotional harm that affects relationships, school and recreation? Finally, have you tried to get the young person any counseling or other help? Involuntary stabilization is the last resort, not the first. Severe intoxication alone will not meet the criteria. The Criteria A parent/guardian seeking an apprehension order must produce evidence to a justice of the peace, that a young person: • is abusing one or more drugs severely and persistently; • is likely to deteriorate substantially either physically or psychologically as a result of severe and persistent drug/and or alcohol abuse; • should be assessed by an addictions specialist to determine whether they should be detained at a secure facility to be stabilized; and • has consistently refused to agree to a voluntary assessment, or has had one or more unsuccessful interventions to address his or her alcohol and /or drug abuse. These basic criteria are outlined in the legislation. This act provides for up to seven days of involuntary stabilization in a facility for this purpose. It does not allow involuntary “treatment” after stabilization. Ongoing treatment, whether in a facility or in a community-based addictions service, is voluntary. If there is evidence that the youth meets the above criteria, a justice of the peace may issue an apprehension order that authorizes the police to search for, apprehend and transport the youth to a stabilization facility to be assessed by two addictions specialists. When the addictions specialists have assessed the youth, they will make a decision whether to issue a stabilization order. Youth Drug Stabilization (Support for Parents) Act Addictions specialists are experienced in the area of youth substance abuse and must meet specific professional qualifications and experience. Only addictions specialists working with designated stabilization facilities can issue a stabilization order, and can do so only after the youth is brought to the stabilization facility by police. 3 The Process In order to have your son or daughter apprehended and placed in a stabilization facility: 1. You must contact Centralized Intake - Youth Addictions Service at 1-877-710-3999 and tell them you are considering involuntary stabilization for your son or daughter. 2. The Centralized Intake - Youth Addictions Service will help you determine the suitability of this option for your son or daughter. 3. If involuntary stabilization seems to be the best option, the Centralized Intake - Youth Addictions Service will provide you with an application form and help you with the process. 4. The application form is filed with a justice of the peace. What happens next? If the justice of the peace is satisfied that the basic criteria in the legislation have been met, he or she may grant an apprehension order. You will also be asked to provide additional information about the youth that will help stabilization facility staff care for the young person and develop a treatment plan. You must then take the apprehension order to the police station in your area. On the basis of this order, police will apprehend the youth and take him or her to a designated stabilization facility. You will be expected to maintain contact with facility staff and participate in planning meetings when required. Addictions counselors will work with your son or daughter and develop a treatment plan with them to follow after they are discharged. Parents are responsible for making sure they have made arrangements in advance for discharge. This responsibility includes transporting and receiving the young person at home and may include taking the individual to a treatment facility if he/she agrees to voluntary residential treatment after the stabilization period. Please remember that the youth is not receiving involuntary “treatment” at the stabilization facility. Stabilization means getting the substance out of the body and stabilizing health. This process prepares the youth for ongoing treatment after discharge from the facility. If at any time during this period an addictions specialist believes that the youth is able to make a reasoned decision on treatment, or it is no longer in his or her best interest to be detained, the specialist may terminate the order holding the youth. The youth may refuse to attend ongoing treatment after leaving the facility. This is not grounds for continued detention at the stabilization facility. Stabilization prepares the youth for ongoing treatment and support. Youth substance abuse treatment services are available through the Addictions Foundation of Manitoba and the Behavioural Health Foundation. Services range from school-based and community-based counseling programs to residential programs accessible to youth across Manitoba. For a complete directory of specific organizations and services for adults and youth, visit www.gov.mb.ca/healthyliving/ addictions/index.html. Youth have the right to: • receive help from Legal Aid free of charge; • know why a justice issued an apprehension order for the youth; • receive a copy of the stabilization order; and • appeal the decision to issue a stabilization order to a Review Panel. As soon as possible after apprehension by police, youth will be informed of their right to contact a lawyer and will be given the phone number for Legal Aid. If the youth contacts a lawyer, the lawyer will explain their role and offer to help . Manitoba Advocate for Children and Youth - December 2018 In Need of Protection: Angel’s Story Addictions Foundation of Manitoba. (2018). Annual report. Online https://afm.mb.ca/wpcontent/uploads/2018/10/Addictions-Foundation-of-Manitoba-Annual-Report-2017-2018.pdf Anda, R. (n.d.). The adverse childhood experiences study: Child abuse and public health. Prevent Child Abuse America. 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