Cooper died at age 5. His case fell through the cracks, advocate finds in latest review

Cooper was five years old when he died from cancer. A smart, shy little boy, his medical needs were complex, his home life tumultuous.

The latest report from Alberta's child advocate shows how Cooper fell through the cracks of the provincial child intervention system long before the disease claimed his life.

The police were notified about violence in his family home many times, particularly during the final year of his life.

There were arguments at the hospital. Calls to police. Reports of substance abuse.

'She struggled to keep him safe'

His abused siblings were removed from the family home. But due to his medical needs, Cooper remained with his mother, even as her partner became increasingly violent.

Caseworkers decided that Cooper's stepfather should no longer be in the family home.

But when the boy and his mother moved back to their home community, all contact with government caseworkers ceased.

A plan detailing the need for ongoing intervention was drafted but never followed.

Cooper's home community would not accept the intake, and child intervention involvement ended.

Even as Cooper lay on his deathbed, his mother and her partner argued at the hospital, yelling at one another until police were called.

Del Graff, Alberta's child and youth advocate, said Cooper's case should inspire changes in the way child intervention cases are handled.

Graff is calling on the Ministry of Children's Services torevise its guidelines regarding file transfers and develop "a clear escalation process" to resolve any difficulties one of four recommendations made public in a report released Tuesday.

"Attempts to transfer his intervention file were not successful and child intervention involvement ended," Graff wrote in his report.

"Cooper was left at risk; he required ongoing monitoring and supports to ensure his safety."

"[The mother] was Cooper's primary support person, but she struggled to keep him safe. She needed help from child intervention services to address the substance use and violence in her home."

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Cooper's case was among 13 deaths examined in the latest report from Alberta's child advocate.

The report reviewedthe circumstances of 13 young people, 11 of whom passed away between October 1, 2019, and March 31, 2020. The report also includes a young person who died prior to this time, but whose review was stayed until March 2020, and another young person whose review was published in June 2020, a year after his death.

Each mandatory review included in Graff's investigation provides the history of the young person's involvement with government intervention services and the circumstances of their deaths, detailing the lives of minors who were receiving intervention services at the time of their deaths, or within two years of their deaths.

Of the 13 children, sevendied from medical complications, one from hypothermia, one from pneumonia, two in a house fire, one from a head injury and one from sleep-related causes. Five were identified as children in need of intervention at the time of their deaths, and eight were identified as such within two years of their deaths.

While the report does not assign blame, it provides insights into breakdowns and failures within the government child intervention system.

Cora and Elliott

Graff's second recommendation which calls for better collaboration among community-based agencies serving children and their families relates to siblings Cora and Elliott, who died in a house fire.

Cora, seven, died at the scene. Elliot, five, succumbed to his injuries a week later.

Graff said both experienced significant trauma from exposure to family violence and ongoing abuse and neglect.

After being released from foster care, they came to school unclean and hungry. There were allegations of sexual abuse.

The mother, who struggled with substance abuse, was getting help in her community but there was no communication among the various agencies involved with the family.

That unco-ordinatedpatchwork of services left the children vulnerable.

"Caseworkers tried to address the presenting concerns. However, addressing instances of abuse as separate events in isolation of each other, rather than exploring their cumulative impact, has little effect on long-term safety.

"For Cora and Elliot, opportunities were missed to intervene and provide support that focused on their trauma and its impact on their development. Adequately supporting children who experience abuse and neglect requires collaboration and co-ordination of services."

Lucas

Lucas, 16, froze to death after a house party.Graff said the teen's death highlights the need for whole family residential treatment programs within Alberta.

Lucas, a Cree teen who lived in his First Nation community for most of his childhood, was "athletic, funny and a natural leader" but soon became involved in gang activity.

At 12, he was shot in the back while walking home from a friend's house and was moved into a residential treatment program in Saskatchewan for his own safety.

Over the next six months, there were shootings reported at the family's home and written threats directed at Lucas for leaving the community. His parents struggled to cope with their circumstances and began abusing drugs and alcohol.

One year into his treatment, his family left Alberta and joined Lucas in whole family treatment.

This family was committed to change but unable to achieve it in the environment they were in.- Del Graff

Aboutone year after returning to Alberta, Lucas left a house party and never returned home. His body was found two days later.

Lucas and his family had received "exceptional support" from child intervention services, Graff said, but were unable to get the treatment they needed in their home province.

[The family treatment program] had a profound and positive impact; however, there were significant barriers to using the strategies they learned after they moved back to Alberta.

"This family was committed to change but unable to achieve it in the environment they were in."

Roy

A fourth recommendation resulted from the investigation of the death of Roy, 19, who died from pneumonia caused by an undetermined infection.

The advocate found that Roy, who was exposed to drugs in utero and had a history of violence and behavioural problems, may have benefited from earlier planning for adult services.

Graff also found that Family Support for Children with Disabilities (FSCD) legislation and policy are not aligned regarding services available to children up to the age of 18.

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Without clear timelines, there is ambiguity in how the policy is interpreted and applied, Graff found. FSCD policy should clearly indicate that children and families are able to access out-of-home placements up to the age of 18, if needed, he said.

"Although these young people come from different backgrounds and circumstances, it is important to remember them as individuals and that their deaths were a loss to their families and communities," Graff said.