In their silence, support workers failed boy who died at 17, Manitoba children's advocate says

Only one person knew the extent to which a spiralling drug addiction was derailing thelife of an Indigenous teenager in child and family services care in southernManitoba but that person never spokeup, the Manitoba children's advocate says.

In the agency's first public investigation into a child's death, the Manitoba Advocate for Children and Youth concluded supporting agencies tried to help the boy, who died in 2016, but they worked in isolation from each other.

He was identified in the report as Circling Star,which is his spirit name.

"They weren't talking with each other and working with each other in a way that was actually meaningful for him," children's advocate DaphnePenrosesaid at a news conference Friday morning.

In one example, the report says nobody but an addictions counsellor appeared to know about and addressthe suicidal thoughts the teenagerexpressed.

His story is not uncommon. He was a young Indigenous youth who lived in a First Nation community and the service equity wasn't there.-DaphnePenrose

The worker referred Circling Star to other agencies for general help, but did not think the boy'sworsening drug addictions a threat to his health and safetyshould be explained to hisparents, the report said.

"It is unacceptable that Circling Star's parents were never afforded any meaningful opportunities to be brought into the treatment plan that was being used with their son," the report read, which said his mother never knew how bad it got.

Unsafe placements

Unaware of the depths of the boy'sdespair, Child and Family Servicesclosed their file on him three times. He was placed in unsafe homesand no CFSworker appeared to follow up after hearing theboy's father was reportedlyabusive. They repeatedly failed to meet minimumstandards of care, Penrose said.

The reportsaid Circling Star'sschool did not appear invested in the root causes of his struggles,his parents never knewwhy he wasdischarged from a mental health facility after only a day and probation workers did not ensure he followed court orders.

Time and again, support workers should have intervened but didn't, Penrosesaid.

"His story is not uncommon. He was a young Indigenous youth who lived in a First Nation community and the service equity wasn't there."

Jerry Daniels, grand chief of the Southern Chiefs' Organization, said the silence between agencies is putting lives at risk.

"People really need to start saying, 'I need to take responsibility,'" he said.

The teendiedin summer 2016 after his vehicle skidded off the road. He was driving and was impaired at the time, according to authorities.

Hispersonal details could not berevealed in the report because he was involved in the youth criminal justice system due to a 2013 arson conviction.

Circling Star became involved with a CFSagency under the Southern First Nations Network of Carewhen he ran away from homeat 13, after learning his dad was not his biological father. Thechildren's advocate believes the boy, who prior to that had ahappy childhood, never recovered from that disclosure.

In the following years, CFSworkers saw no role for themselveswhen Circling Star's family arrangementsbroke down and he was bounced from home to home.

When CFSeventually intervened, workers complied withCircling Star's wishes and agreed to housing placements that weren't in his best interests,Penrosesaid.

Interventions too late

"TheCFSagency provided services which were reactive to what was happening in the moment, with no demonstrated vision of a longer-term plan," says the 104-page report.

In the last fouryears of his life, the teen struggledwith significant drug and alcohol misuse.

He began acting out at 14, when he started attending high school in a new community. His behaviour worsened and he started to attend school while intoxicated,threatening school staff and carrying a weapon.

The school's course of action, rather than investigating why he was rebelling, was to suspend him.

The report concluded his high school made no demonstratedefforts to mediate peace betweenCircling Star and the teacher who often reprimanded him, and made little investment in improving his academic standing.

"The school's approach to suspensions was to lay all of the blame at Circling Star's feet," the report said.

Penrosemade six recommendations in her report:

• A provincial strategyto train service providers to share information across systems.
• Limiting, reducing or phasing out school suspensions or expulsions, except in cases where public safety is at risk.
• Easier access to mental health supports foryoung people.
• A youth addiction action strategy.
• Better communication in the Department of Justice.
• TrainingCFS workers on minimum standards.

Penrosesaid a progress report on the status of therecommendations would be released in six months.

A provincial spokesperson said the government acknowledges the lack of communication and introduced legislation last year to ensureagencies working with at-risk kids can share information more effectively.

Authority to disclose

This is the first review into the death of a child incare that Manitoba's children advocate has been able torelease after the independent body's powerswere expandedearlier this year.

The additional powers were recommended in 2013 by the inquiry into the death of Phoenix Sinclair, a five-year-old girl who was beaten to death by her mother and her mother's boyfriend after social workers closed her file.

Penrose is expecting to release eight to nine more reports by next spring. One of those investigations will be a review into the death of Tina Fontaine. The discovery of her body in the Red River in 2014 spurred the push foran inquiry into missing and murdered Indigenous women and girls.