'A child falling through the cracks': Teen failed by B.C. and Alberta child protection systems, report finds

By the time "Romain"was 11 years old, he told social workers he already felt like he had been "passed around for 10 million years."

The troubled child had six more to go before he died of a fentanyl overdose in May 2017.

During that time, he wasbounced between family members, care homes and youth custody facilities in both British Columbiaand Alberta as relatives and social workers alikestruggled to deal with his complex web of problems.

In a report released Tuesday, B.C. Representative for Children and Youth Jennifer Charlesworth described Romain as a "polite, kind and gentle soul" failed by child protection services whose inability to communicate left him without the services and attention he desperately needed.

And she called on B.C.'s Ministry of Children and Family Development (MCFD) to act to make sure more vulnerable"interprovincial children" don't fall through the cracks, as they're shuttled from province to province in search of a home.

"This boy and his family deserved much, much better," Charlesworth said, in a news release accompanying herreport.

"The best interests of Romain were not fully considered and acted upon, and the result was as predictable as it was tragic."

'Apredictably precarious situation'

Charlesworth's report Caught in the Middle makes six recommendations related to both the process through which children in care are moved from province to province and the way in which the MCFD handles questions about ethnicity and trauma as they relate to vulnerable young people.

Romainis a pseudonym for the teenager who died of a fentanyl overdose in May 2017 while placed in an emergency staffed residential home in B.C.

He was diagnosed and medicated for psychiatric disorders that saw him act out in violent and unpredictable waysthat became too much for family members to handle alone.

He developed substance abuse problems and exhibited suicidal behaviour and ultimately came into conflict with the youth criminal justice system.

Romainwas first moved to B.C. at the age of 13 when Children's Services in Alberta placed him with a female relative.

But Alberta didn't follow a protocol between the provinces that would have required itto give the MCFD notice.

"This was the first in a string of miscommunications and dropped handoffs between the two provinces that culminated when, despite Alberta's informal agreement to fund a highly specialized residential resource for Romain four years later,was never confirmed in the interprovincial agreement," the report says.

"No action was taken by B.C. to create that resource, leaving the teen in a predictably precarious situation and contributing to the events that led to his death."

'Confusion, miscommunication and discord'

Charlesworth's report says that interprovincial cases are rare for social workers but have resulted in previous tragedies, including a case in 2013 when Calgary paramedics found 15-year-old Alex Raditadead from complications related to untreated diabetes and starvation.

His parents were later convicted of first-degree murder in his death.

"A contributing factor to Alex's deteriorating health was the fact the family had relocated from B.C. to Alberta in an effort to avoid child welfare involvement," areport into his death said.

"There was insufficient child welfare followup by B.C. or notification to Alberta following Alex's relocation."

In another case investigated by Charlesworth's predecessor, a young Indigenous girl was confined to a windowless basement room in Saskatchewan after being placed with a maternal grandfather, despite his lengthy criminal history.

The B.C. representative can't make findings about Alberta's role in the events that led to Romain's death, but Charlesworth said she wants to see the MCFDtake a leadership role in improving the protocol that governs the movement of children between provinces and territories.

She also called on the ministry to dedicate a co-ordinator tasked with supporting, tracing and monitoring interprovincial cases.

"This investigation pointed to a child falling through the cracks and his best interests getting lost in confusion, miscommunication and discord between provincial child welfare authorities," herreport says.

A need for greater accountability

The report quotes B.C.'s deputy director of child welfare, who said: "We've taken our eyes off the ball ... Likely this report will put it on the front burner again."

In a statement, Children and Family Development Minister Katrine Conroysaid work is already underway to address several of the key issues contained in the report, including the appointment of a co-ordinator to oversee interprovincial cases.

"It is clear to me that there must be greater accountability centrally and more hands-on support from this office to assist staff on the ground when it comes to managing interprovincial cases," the statement said.

"What is most disheartening for me as minister is to be making changes after the fact, in the wake of a young life that was filled with trauma and abuse."