WARNING: This story contains graphic and disturbing content.
The report from a fatality inquiry looking into the case of a four-year-old Alberta girl who died while in care was released on Wednesday, offering nearly two dozen recommendations to prevent a similar case from unfolding again.
The inquiry looked into the story of a girl known as Serenity. Details that emerged after her 2014 death shone a spotlight on Alberta’s child welfare system. An autopsy confirmed the Indigenous girl died from “blunt cranial trauma” resulting from an accidental fall off a swing at her guardians’ residence in Maskwacis, Alta. Serenity was on life support for 10 days before she died.
Serenity’s guardians, who were relatives, were charged in 2017 with failing to provide the necessaries of life. However, those charges were later stayed.
READ MORE: Charges stayed against guardians of 4-year-old Serenity
“What led up to her death started the day she was removed from the care of her mother… on Jan. 11, 2011,” Alberta judge Renee Cochard said in the report released Wednesday.
The review took into account testimony from 18 witnesses as well as evidence from a preliminary inquiry into Serenity’s death and paints a dismal picture of insufficient communication between various people and organizations in both the health sector and in the field of child welfare, often times indicating warning signs of potentially inadequate or negligent care were ignored or not properly acted upon.
The report also found a number of child welfare workers did not follow through on their mandate of always putting children’s interests first and that Serenity’s health and well-being seemed to deteriorate after being separated from her mother, who mainly had her children taken away from her in connection with the domestic abuse she faced from her partner, according to the report.
“There is no indication in any of the documentation that Serenity was not being properly looked after while in… (her mother’s) care,” Cochard writes. “In fact, the opposite was true.
“Serenity was growing, found to be healthy by the nurse and had a mother who was concerned about her daughter’s well-being while having to cope with the fact that her two older children… had been apprehended from her care.”
The report notes Serenity was taken to a doctor in July 2013 after a caseworker expressed concerns about the girl appearing to be losing weight and other issues. The doctor had expressed concern about the weight loss but the report notes that “from Nov. 29, 2013 until her injury on Sept. 18, 2014, Serenity was not seen by (the same doctor)” and “there is no evidence before the inquiry that she was seen by any other medical practitioner during that 10-month period.”
The review found that in some cases when Serenity was seen by a doctor, it appears they were not provided with all the context of Serenity’s medical history and family history.
After her fall in 2014, Serenity was taken to a hospital in Ponoka before being airlifted to the Stollery Children’s Hospital in Edmonton, where she later died. The report says the doctor who saw her at the rural hospital noted a bruise on her cheek and on her genital area and found the girl to be underweight.
“Her face just looked wasted,” the doctor said.
READ MORE: Serenity’s mom vows to sit vigil through Alberta court proceedings
At the Stollery, another health-care worker noted physical signs that could point to possible sexual abuse while a doctor at that hospital found Serenity to be “extraordinarily emaciated.” The doctor also noted lesions and bruising — including in the girl’s genital area — and indicated the possibility the girl’s weight could be linked to insufficient protein intake. The doctor also suggested the girl’s condition could have played an indirect role in her accident, as perhaps her lack of strength may have come into play.
Two days prior to Serenity’s death, a caseworker used the Stollery doctor’s assessment in an application to have Serenity taken away from her guardians through kinship care.
A medical examiner’s report, which was not completed until nearly two years after Serenity’s death, found no signs of sexual abuse. It also found no evidence of chronic infection or malnutrition but noted there could be other causes for Serenity weighing just 25 pounds when she died that an autopsy would not be able to determine.
Report offers 20 recommendations
Cochard’s report concludes by offering 20 recommendations to the province intended to prevent a similar death from occurring again.
Among some of the main recommendations are that Children’s Services support young Indigenous mothers and make the removal of children from their parents’ home “a last resort only,” that medical examiners’ reports be completed in a “timely manner” and within six months of a death “to provide families with closure and avoid misconceptions,” that a child’s biological parents should have access to legal assistance through Legal Aid right away when their child is first taken away from them and that lawyers representing biological parents should have access to same disclosure of documents as the children’s lawyer.
One of the recommendations says “foster parents, kinship caregivers and private guardians should receive all past medical records of the children they are caring for in a timely manner.”
“Costs associated with the provision of the records should be paid by the government of Alberta.”
Global News requested a statement from Alberta Health Services on the medical records recommendation. A spokesperson for the health authority said it “has been requested by the inquiry to respond to Recommendation 12” and that “AHS is currently reviewing this recommendation.”
Children’s Services Minister Mickey Amery tweeted out a statement in response to the report.
“Although we cannot undo what has been done, substantial changes have been made to help prevent this tragedy from happening again,” the statement reads.
Amery also noted Serenity’s Law, passed in 2019, which expands reporting options when it comes to child welfare.
“We will continue to make and support improvements going forward, including reviewing the fatality inquiry judge’s recommendations with all of the seriousness this death deserves.”
Cochard’s report emphasizes throughout that Serenity’s decline appeared to be linked to her being separated from her mother.
“The evidence before the inquiry is that until November/December 2012, Serenity was a healthy young child,” the review says. “Six months later, in the summer of 2013, there were concerns regarding her weight and failure to thrive.
“One year later, she is found to be ’emaciated.’ The inquiry is left with many questions as to how no one around Serenity took notice of what was happening to this young
“What is clear from the notes is that… (Serenity’s mother) was unwavering in her desire to have her children returned to her. She was trying very hard to follow through with directions given to her, but with little actual support given to her by Children’s Services.”
NOTE: Serenity’s last name and other names have been left out of this article by Global News in order to protect the identities and privacy of Serenity’s siblings.