Warning: This story contains details which may be disturbing to some readers
A report by a judge into the death of a mentally handicapped Alberta woman who was neglected by her family is making 13 recommendations, including better funding and programs for people with disabilities.
Betty Anne Gagnon was developmentally delayed due to oxygen deprivation at birth, and had the mental capacity of a young child. Although she was capable of looking after her personal needs, she was in need of supervision at all times, not able to live alone and employable in a limited capacity.
Gagnon, who was 48, had been confined in a basement, a dog run and a converted school bus with no heat, running water or electricity at an acreage east of Edmonton prior to her death.
A medical examiner determined she died in 2009 of a blunt head injury that was caused by either a blow to the face or an accidental fall. An autopsy showed she was covered in bruises and “grotesquely malnourished” when she died. There were just 30 kilograms, or 65 pounds, on her tiny five-foot two-inch frame. She was also legally blind due to glaucoma.
In 2013, Gagnon’s younger sister, Denise Scriven, and brother-in-law, Michael Scriven, were sentenced to 20 months each in jail after pleading guilty to failing to provide the necessaries of life.
WATCH: They spent time in jail for failing to provide the necessaries of life for a developmentally disabled Alberta woman. On Wednesday, Denise and Michael Scriven testified at a fatality inquiry into Betty Anne Gagnon’s death. Vinesh Pratap reports. (May 2017)
Gagnon lived in a number of group homes as an adult, but was living with the Scrivens at the time of her death.
READ MORE: Friends call for change as fatality inquiry gets underway outside Edmonton
The fatality report from Provincial Court Judge Michele Collinson, who conducted a fatality inquiry last June, said the couple struggled with the demands of caring for Gagnon, while at the same time, they deteriorated into abuse of drugs, paranoia, and depression including suicide attempts.
The report said Betty Anne had developed behavioural issues, including plugging the toilet, excessive masturbation, wandering off and feces smearing.
“The feces smearing became extreme; for example, she would mix her feces with water, pour it on herself, pour it on her bed, make holes in the drywall and pour the mixture into the walls through the holes.”
“The home, bedding and Betty Anne required cleaning several times a day. The drywall often needed replacement.”
The last few months of Betty Anne’s life were tragic. “The couple employed abusive, even torturous methods to deal with the behavioural issues,” Justice Collinson wrote.
The couple recorded their abuse on video. Judge Collinson detailed one instance of abuse recorded in the week leading up to Gagnon’s death:
“Denise is wearing rubber gloves and repeatedly slapping Betty Anne’s buttocks as Betty Anne is leaning over a makeshift toilet. Denise tells Betty Anne that she has earned 60 slaps for such offences as sleeping all day, not saying good morning and brainwashing Michael by “getting in his head.” Michael is heard in the background calling Betty Anne, a “dumbass.” Denise lost count at one point and started over. Betty Anne is seen biting her lip and can be heard crying and screaming. Betty Anne is heard to say, “how many more” and “ouch.” Denise is heard to tell her to scream loudly. The video has a date of November 14, 2009.”
Gagnon died six days later.
READ MORE: Pair who abused relative sentenced to 20 months
The report said the Scrivens asked officials for help caring for her sister, but noted they either didn’t follow up or weren’t persistent in their requests.
It also suggested that there were many missed opportunities for authorities to intervene, which could have prevented the “tragic and unnecessary death.”
“The death of Betty Anne Gagnon is a heartbreaking tragedy,” Minister of Community and Social Services Irfan Sabir said in a statement.
“We owe it to her to take all needed and necessary actions to avoid similar tragedies from happening again.”
The 13 recommendations in the report include: making sure there’s adequate funding for programs, taking immediate steps to address emergencies and reviewing programs for people with disabilities who live in rural areas. The report also recommended better emergency respite care for caregivers.
Alberta launched a review of the Persons with Development Disabilities (PDD) program in January.
The program includes services that help people live at home, get job training and take part in community activities.
The government said at the time that it sought input from people receiving assistance, their families and staff.
Sabir said the government has made significant changes to improve the safety and well-being of Albertans who receive support from the PDD program, including boosting funding by $150 million.
“These changes include implementing new training for staff, prioritizing individuals with urgent needs for PDD supports, creating new accountability mechanisms and launching a provincial helpline to report suspected abuse or neglect,” Sabir said.
The phone line to report concerns will be launched in a few weeks, the province said, adding calls will be tracked and followed up on with set timelines.
The province said further action would be looked at as part of the PDD review.
Fatality inquiries do not place blame; instead, they aim to identify the victim and circumstances of their death, and make recommendations on how to prevent similar incidents.
—With files from The Canadian Press