Case of boy found 'naked, frightened' in Saskatoon parking lot shows gaps in group home system: report
SASKATOON -- On June 2 of last year, staff were just arriving to work at a Tim Horton's located in the city's north end when they found a seven-year-old boy in the parking lot "naked, frightened and non-verbal."
The workers took the boy, who was "distressed" but appeared unharmed, inside the restaurant.
They gave him clothes, something to eat and contacted the police.
It was later learned the boy had escaped from a group home over a kilometre away.
A new report from the province's children's advocate delves into the events of that day and examines what may have led to the incident.
During a news conference Wednesday morning, Advocate for Children and Youth Lisa Broda said the report's findings point to the need for change in the province's group home system.
"Our investigation found the (Ministry of Social Services) oversight of group homes is severely lacking in coordination, continuity and then much of the work falls to ground level positions that are not resourced to take on this added responsibility," Broda said.
Following the June 2 incident involving the boy, referred to as "Elijah" by Broda to shield his identity, ministry-conducted investigations into allegations of medical neglect and abuse in the group home found most were substantiated, according to the report.
The ministry found inappropriate discipline occurred in the privately-operated group home located in Lawson Heights and identified examples of sometimes "egregious" medical neglect, which in one instance sent another child in the home to hospital.
The child who required hospitalization was malnourished, according to Broda.
Four children, all with complex needs, lived in the home. Elijah is diagnosed with autism spectrum disorder and moderate intellectual disability, according to the report. The boy communicates using gestures and sounds.
The lone staff member who was working the night Elijah escaped had last checked on the boy sometime between 3 and 4 a.m. and did not detect his absence, the report says.
According to the report, the group home had previously prepared 63 incident reports involving Elijah. Eleven of the incident reports were related to the boy either attempting to flee or successfully fleeing the home.
"The ministry did a thorough and adequate investigation and review into the home. However, they did not do this until after the fact, which is reactive and not proactive in getting to the issues before deep-seated problems result in crisis.
"The higher onus on the ministry to ensure the children are being cared for commensurate to their basic needs was not met," Broda said.
"There were no sensory or therapeutic toys or tools in the home, and COVID protections were insufficient."
The lack adequate of COVID-related precautions was especially significant given that a child in the home was immunocompromised, according to the report.
Physical restraints were also used in the home, the report said, a practice that ran contrary to the operator's own policy.
The ministry also found "internal dysfunction" among group home staff and that a senior staff member "had not been forthcoming or honest" during the investigation, the report says.
The company, which successfully obtained a contract to establish the provincially-funded home in 2019, provided notice it would cease operating the home on July 30.
While the name of the company was not released by the children's advocate, CTV News has identified CBI Health Group as the firm which operated the home.
In an emailed statement, the Ontario-based company said it is "taking the time to thoroughly review and absorb" Broda's findings.
"Quality of care is our top priority. We continue to work with the Ministry of Social Services in addressing any areas of concern," the statement said.
The company said it would not comment on specific incidents outlined in the report due to privacy considerations.
CBI confirmed it does not permit the use of physical restraints and said there are "clearly defined policies and procedures related to discipline" in place.
The company said it also has clear "rules and expectations" around COVID-19 precautions.
CBI said it ceased operating the group home in September. The firm said it still runs two short-term placement homes in Saskatchewan with child and family programs.
In her report, titled Someone to Watch Over Us, Broda makes three recommendations based on her investigation.
In her first recommendation, Broda calls on the ministry to revamp its group home oversight structure.
The suggested changes include creating a leadership role to ensure oversight in group homes and making it clear "what evidence is needed" to verify if group homes are meeting quality of care standards.
Broda's second recommendation is that the ministry develops a permanent resource for group home operators that provides a point of contact, support and offers skill development for group home providers.
The advocate's third recommendation is that the ministry "enhance" its process for approving group home openings to include "identifying and verifying qualifications."
"However, it cannot be overstated that although rigorous oversight is critical it's imperative to make all efforts to prevent children from entering the system in the first place. Prevention-focused services is key to giving children their best chance to thrive and stay connected to the most important people in their lives," Broda said.
The focus of her report, Elijah, started off as a temporary ward of the ministry, but now reunification with his family is considered unlikely.
In 2019 he became a long-term ward of the ministry, meaning the provincial government is responsible for his care until he turns 18.
In an emailed statement, the Ministry of Social Services said it "accepts the recommendations" outlined in Broda's report.
"We appreciate the vital work of the Office of the Advocate for Children and Youth, and their efforts to ensure the safety and well-being of Saskatchewan’s children and youth," the statement said.