Turner Review and Investigation, September 2006
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ccover-vol1-outlines.inddover-vol1-outlines.indd 1 99/10/2006/10/2006 112:55:152:55:15 PMPM TurnerReview and Investigation September 2006 PETER H. MARKESTEYN, M.D., F.C.A.P. Newfoundland and Labrador Child and Youth Advocate’s Delegate DAVID C. DAY, Q.C. Legal Counsel Volume I © 2006, by Government of Newfoundland and Labrador St. John’s, NL A1B 4J6 www.gov.nl.ca No part of this publication may be reproduced, stored in retrieval system or transmitted in any form or by any means without the prior written consent of the publisher. Library and Archives Canada Cataloging In Publication Findings of Turner Review and Investigation / by Dr. Peter H. Markesteyn, Delegate of Child and Youth Advocate of Newfoundland and Labrador, and David C. Day, Q.C. ISBN 1-55146-289-3 1. Child Welfare - Newfoundland and Labrador. 2. Child Death Review - Newfoundland and Labrador. 3. Child and Youth Advocate - Newfoundland and Labrador I. Markesteyn, Peter H. II. Day, David C. III. Title [pending] [pending] [pending] Volumes One, Two and Three of the Findings of the Turner Review and Investigation, by Dr. Peter H. Markesteyn, M.D., F.C.A.P. and David C. Day, Q.C. are accessible, electronically, at the website of the OfÞ ce of the Child and Youth Advocate: www.ChildAndYouthAdvocate.nl.ca Dedication Zachary Andrew Turner 18 July 2002 to 18 August 2003 and his father Andrew David Bagby 25 September 1973 to 05 November 2001 Volume I Turner Review and Investigation i ii Turner Review and Investigation Volume I FOREWORD This report does not include all that is known about Shirley Turner. My mandate is limited to exploring the actions or inactions of government bodies with regards to policy or legislation and practices, and how that impacted on Zachary Turner. I have also described and discussed some of the actions of persons other than government. This was done in order to account for what was known, and therefore could have been known, by officials operating in the judicial, health and social service pillars. Some of the forces that played a role in the tragic death of Zachary, we will never know. We have some knowledge of the intense emotional toil this child’s death had on his grandparents, his godparents, Shirley’s children and Shirley’s friends. I have observed some of the anguish in the hearts and minds of the frontline social workers who keep asking themselves, “Where did we go wrong? How did we fail this child?” This Report does not blame anyone. It is not meant to do so. It was commissioned to me, as an outsider with some knowledge of Newfoundland and Labrador’s society, to find out not who was wrong, but what was wrong with the system that resulted in this preventable tragedy. Volume I Turner Review and Investigation iii Foreword Zachary was in the care of his mother when he should not have been. I reach this conclusion, not on hindsight - which is obvious to all - but based on information which could have been known, if investigated, by the parties responsible for Zachary. In my judgment, based on the facts that became known to me, the recommendations that I have made, if implemented, will serve to reduce the likelihood of the death of a child occurring under similar circumstances. iv Turner Review and Investigation Volume I Preface These three volumes contain the Findings which result from my Review and Investigation into the circumstances of and surrounding the death of Zachary Andrew Turner in the Atlantic Ocean off the coast of Foxtrap, Newfoundland and Labrador, on 18 August 2003. Thirteen-month old Zachary, at his passing, was a client of the St. John’s Regional Health and Community Services Board, an agency of the Government of Newfoundland and Labrador (since absorbed - on 01 April 2005 - into the Eastern Regional Integrated Health Authority). I conducted the Review and Investigation and prepared the Findings for the Child and Youth Advocate, Darlene M. Neville, an officer of the House of Assembly of the Province of Newfoundland and Labrador, whose Office appointed me Delegate of the Advocate on 17 May 2005 under section 14 of the Child and Youth Advocate Act. Volume I Turner Review and Investigation v Preface My duties as Advocate’s Delegate were performed by me in partnership with my experienced and highly respected legal counsel, David C. Day, Q.C., of St. John’s. The Findings are based on examination of about 100,000 pages of documents and reference materials, and some 150 interviews. The Findings are organized into 13 chapters and 10 appendices (which include tables, maps and photographs). A summary of my Recommendations is in the last chapter. In preparing the Findings for the Child and Youth Advocate, I was, as the Advocate’s Delegate, determined to assist the Advocate to fulfil her mandate under section 3 of the Child and Youth Advocate Act, (a) to ensure that the rights and interests of children and youth are protected and advanced and their views are heard and considered; (b) to ensure that children and youth have access to services and that their complaints relating to the provision of those services receive appropriate attention; vi Turner Review and Investigation Volume I Preface (c) to provide information and advice to the government, agencies of the government and to communities about the availability, effectiveness, responsiveness and relevance of services to children and youth; and (d) generally, to act as an advocate of the rights and interests of children and youth. I am particularly indebted to the Premier of the Government of Newfoundland and Labrador, The Honourable Daniel E. Williams, Q.C.; the Speaker of the House of Assembly, The Honourable Harvey Hodder; and the Clerk of the House of Assembly, John A. Noel, Barrister and Solicitor, for their confidence in, and encouragement and support of me as the Child and Youth Advocate’s Delegate in the performance of my Review and Investigation into this tragedy. A special word of thanks to the three Calgary consultants who volunteered their expertise and time in answering our general questions without specificity to the matter under investigation and review: Volume I Turner Review and Investigation vii Preface Gayle Gilchrist James, MSW Former Professor, Faculty of Social Work University of Calgary John W. Mould, BSW, MSW Child and Youth Advocate Alberta Children’s Services Richard Frederick Ramsay, MSW Professor Emeritus of Social Work University of Calgary. Particular thanks to our project consultants who, through their special knowledge and experience in the field of social services, provided me with valuable insight. They also donated many additional hours to this undertaking without charge: Janet Mirwaldt, BSW, MSW Former Child Advocate Province of Manitoba Janice Christianson-Wood, B.A., BSW, MSW Special Investigator Office of the Chief Medical Examiner Province of Manitoba John P. F. Chudzik, B.Sc., MSW Former Provincial Program Coordinator Manitoba Department of Family Services Child and Family Support Services Branch viii Turner Review and Investigation Volume I Preface Kathleen Kufeldt, MSW, PhD, RSW Former Chair of Child Protection Memorial University of Newfoundland. I am also grateful to Georgina Buddick and Kelly Hall, who provided executive and secretarial support, and John Day and Ronalda Steele, who provided us with both valuable and timely technical support. All worked long and tirelessly in preparing this text for publication and I thank them for their caring and competent work. My special thanks to Dr. Ralph Butler and his wife Lorna for their kind hospitality during the last weeks I was in St. John’s finalizing the report. Finally, I am indebted to my wife Jane for her flexibility, understanding and patience in putting up with my lengthy absences from home. Peter H. Markesteyn, M.D., F.C.A.P. Winnipeg, Manitoba 31 July 2006 Volume I Turner Review and Investigation ix x Turner Review and Investigation Volume I Table of Contents Volume 1 CHAPTER 1 Introduction to Findings of Review and Investigation 1. Introduction ...........................................................................................3 2. Review ......................................................................................................4 3. Findings ..................................................................................................4 Endnotes .................................................................................................6 CHAPTER 2 The Child and Youth Advocate 1. Child and Youth Advocate Act in Newfoundland ........................9 2. Child and Youth Advocate Legislation Elsewhere ......................9 3. Functions of Child and Youth Advocate Legislation ................10 4. Beneficiaries of Child and Youth Advocate Act in Newfoundland .....................................................................................16 Endnotes ...............................................................................................17 CHAPTER 3 Origins and Terms of Reference of Review and Investigation 1. Origins of Review ...............................................................................23 2. Appointment as Delegate to Conduct Review .............................25 3. Mandate of Review .............................................................................26 4. Interpretation of Mandate of Review ............................................28 5. Delivery and Reporting Findings of Review ...............................29 6. Disposition of Findings of Review ................................................31 Endnotes ...............................................................................................33