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November 23, 2005

Investigation of Deaths

In 2003 I obtained data on the number of deaths of children in care after months of persistent effort to get an answer to a freedom of information request. In 2004 I again submitted a freedom of information request for updated numbers. When the answer came I discovered to my dismay that they had revised the figures for earlier years, making it look like they can't even accurately count the number of children-in-care who die. At that time the ministry published on its website the data they had provided me; those data are now missing and have been replaced with a new statistics section that fails to report on the number of children-in-care. However, in response to allegations from a social worker who recently retired, the ministry published a "fact sheet" which said "The number of children-in-care is down 16 per cent - from 11,000 in 2001 to 9,000 in 2005." The incidence of deaths of children in care would therefore increase if the number of deaths did not also decrease by 16 per cent over that period. The number of deaths were 9 in 2001, 9 in 2002, 12 in 2003 and 14 in 2004; that's definitely not a 16% reduction, it is an increase in both absolute numbers and in the incidence (deaths per thousand children-in-care). The ministry will likely argue that the numbers are so small as not to be statistically significant, but the issue is how significant are any of the deaths to the government given its handling of investigations.

BC's Chief Coroner recently said that he lacked the resources and legislative authority to complete child death reviews properly. That excuse sounds similar to what he said in a 2002 letter in response to his office's ability to track suicide deaths related to gambling. He wrote that it would be desirable to track gambling related suicides but: "Unfortunately, finite budgets and staffing levels demand that we make choices among a variety of available options." That makes BC stand alone in not tracking gambling related deaths. On April 22, 2002, Patricia Cairns was beaten and strangled to death by her husband who was enraged over her gambling away his life's savings; however, the coroner's report on her death doesn't mention one word about the gambling issue. The Judgment of Inquiry on her death completely left out any investigative findings even though guidelines for such reports suggest they be included. Investigations into unnatural deaths are of little use without the investigative findings.

According to Public Accounts, the Coroners Service budget was $8.582 million in 2001-02, $8.009 million in 2002-03, $8.247 million in 2003-04 and $8.315 million in 2004-05. The cut of $573,000 in 2002-03 was not yet fully restored by the fiscal year ended March 31, 2005. Actual spending was $8.137 million in 2000-01, $8.147 million in 2001-02, $7.516 million in 2002-03 and $7.869 million in 2003-04. The drop in actual spending between 2001-02 and 2002-03 of $631,000 exceeded the budgeted cut. Faced with questions about the cuts, the Solicitor General weakly responded that the budget was under-spent each year while not mentioning that it is a firing offense for any bureaucrat to over-spend when ordered to cut.

On November 21st Opposition critic Adrian Dix asked Solicitor General John Les about the death of Brandon James Seymour who was two and a half years old when he died on June 27, 2003. Dix asked:

"That wheelchair was too big for him, and he occasionally slid down in it. He was waiting for a replacement. On June 27, 2003, his caregiver found him in this wheelchair with the restraint straps around his neck area. He had once again slipped in his chair, and he was not breathing. Efforts to resuscitate him failed. He died that morning. The coroner on the case classified the death as undetermined and offered no recommendations. When the Solicitor General said every case is investigated, is this what he meant?"

In question period this week the Campbell government appears to have adopted a new strategy of hiding behind staff when fielding questions about child deaths. Instead of being accountable for the consequences of its cuts to services the government either says that investigations are not yet complete, or it attacks the Opposition for daring to question the integrity of hardworking coroners and front-line social workers. It is the Campbell government that reduced the number of staff and gave those who remain fewer resources to do their job. The job description for a regional coroner includes the related qualification: "Ability to effectively resolve difficult and politically sensitive problems." Does that include editing reports of local coroners so as to remove content that might embarrass the government? Civil servants can't say and the government won't say.

The Coroners Service provides local coroners with a "Guide to Completing the Judgment of Inquiry". It emphasizes that an individual's right to privacy does not end with his/her death. As an example, in the case of a suicide, it offers a guideline that "must be applied"; rather than detailing private information it instructs coroners to summarize as follows:

"Mr. XXXX was dealing with several issues of personal concern" or "Mr. XXX was concerned about several personal issues."

How can anyone analyze whether teenage suicides have a common cause with reporting like that? How can BC assess whether the expansion of gambling has resulted in increased suicides? Perhaps the Coroner would develop a separate database if he had the resources.

It is time to shed some light on what happens when the experts examine deaths, whether they are deaths of children or deaths of adults. It is not a matter of blaming hard working, under-resourced staff; it is a matter of holding a service-cutting government to account for the consequences of its actions.

 

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