Youth protection too slow to act before toddler's death, Quebec coroner says

WARNING: This story contains distressing details about a child's injuries and death

A child who is five years old or younger should be evaluated by a case worker "without delay" as soon as they are reported to the province's youth protection services,according to a report from a Quebec coroner.

That is the top recommendation in the latest report from coroner Ghane Kamel, who looked into Thomas Audet's deathon June 18,2016. He died shortly after being transported toAlma Hospital in the province's Saguenay region.

He was about two months shy of his second birthday. It had also been about four weeks since his situation had already been reported to youth protection.

An autopsy conducted at the timefound that the toddlerhad sufferedseveral injuries some old and some new including bruising to his head,fractures to hisribs and injuries to his abdominal area.

The coroner's report, which was released on Monday, concluded that the boy died from "blunt abdominal trauma,"but what led to that injury remains unclear.

However, the coroner is adamant that youth protection services should have stepped in more quickly.

"The evaluation of the child's situation has to begin as quickly as possible," Kamel wrote in her report.

Thomas died the day before his case was formally assigned to a case worker with the Directeur de la protection de la jeunesse (DPJ).

Kamel's 26-page report follows an inquiry that took place last fall at the Chicoutimi courthouse.

Red flags missed

According to Kamel's report, the toddler's case was first reported on May 17, 2016.

The DPJ set up a preliminary meeting a few days later, but the mother showed up without herson one of several red flags that were missed, according to the coroner.

Thomas was then evaluated by two pediatricians, who noticed several of the boy's injuries. One of them wrote"possible abuse" in the child's file.

A followup examination was done by a thirdphysician, who determined that the child's injuries were accidental and likely due to the bumps and tumbles of being a toddler.As a result, that physician didnot mention anything to the DPJ.

Days later, the DPJ gotin touch with one of the first physicians who evaluated Thomas. He sharedhis concerns about the boy's well-being.

The boy's case waseventually processed and deemed to be a Code 3, which means it could take about 30 days before a case worker is assigned.

A case worker was formally assigned to the boy's case the day before he died.

"The testimonygathered makes it clear that the evaluation criteria should have led to a Code 1," Kamel wrote. "The delay to assign the file would not have been a factor [in the boy's death]."

Kamel also says the Quebec government should put more resources into the DPJ, in order to reduce the workload of caseworkers.

"Caseworkers were overwhelmed in 2016 and they still are today," the report said. "It is urgent, in my opinion, the improve the service offer in youth protection."

Kamel also wants the Quebec College of Physicians to remind its members of their obligation to contact the DPJ whenever they have reason to believe that the safety and development of a child in their care is being compromised.