Children killed in fire failed by government employees, RCMP: N.L. advocate

The province's child and youth advocate has released a damning investigation into a fatal fire that claimed the lives of two children and one adult.

Carol Chafe's report, A Tragedy Waiting to Happen,was released Tuesday and takes a look at the circumstances surrounding their deathsand the flaws within multiple departments and agencies.

• Nain house fire kills 2 kids, man

Chafe said the children lived in harmful conditions for years, and the end result was a house fire in which two of the three children were killed in 2010 in Nain, Labrador.

These children had numerous encounters with many professionals yet they continued to live in an unacceptable, unsafe environment, detrimental to their health, safety and well-being.- Carol Chafe

"The needs of these children were not met ... right to services not upheld," Chafe said.

The children were three andfour yearsold. The child who was not killed was eight.

She began the investigation in 2013, and it involved interviewing professionals and reviewing case files.

Failed to report child protection concerns

The 123-page report statesthe results showa lack of documentation, lack of comprehensive assessments, lack of collaborationamongall service producers and non-adherence to documentedpolices.

During the course of eight years, Chafe said, the family had multiple contacts with the local community health clinic, the Department of Child, Youth and Family Services, the RCMP, andpublic health nursing provided by the Nunatsiavut Government.

Over that time, the children remained in the care of their mother.

"These children had numerous encounters with many professionals yet they continued to live in an unacceptable, unsafe environment, detrimental to their health, safety and well-being," Chafe said.

Chafe said the Department of Health and Community Services and the Labrador-GrenfellRegional Health Authority failed to report child protection concerns.

The report also noted there was a lack of oversight, collaboration, communication and information sharing, as well as "inappropriate medication prescribing/dispensing and lack of comprehensive nursing assessment"in relation to the health department and health authority.

Italso notedthe Department of Justice as it was known at the time and the RCMP failed to report child protection concerns.

"These deficiencies remain today," Chafe said, citing workload and human resource issues.

Chafe said there isn't one factor or department which contributed to the poor living situations for the three children, but many.

In many cases child, youth and family services responded to the home by referral, not to check up on the children, Chafe said.

"The same goes for the RCMP. They responded numerous times when there was violence in the home and when there was alcohol being consumed," Chafe said, adding information sharing would have meant the children could have been taken out of the home before the fire occurred.

Recommendations

Chafe has made 10 recommendations, which include a review of the practice of prescribing, administering and dispensing of medications by registered nurses in all community clinics within the region.

She also recommends that the Department of Health and Community Services ensure that nursing assessments are being conducted in all community clinics as well as ensuring proper oversight.

To improve communication, Chafe also wants the health,justice, and child and youth departments to develop a committee as a way to share information.

Chafe recommends that the health and child, youth and family services departments collaborate to "complete comprehensive needs assessments of the services being provided in every remote and isolated community" to identify and rectify any deficiencies.

In the meantime, Chafe said proper follow up did happen with the third child and she's confident the child is safe.