Family Vilence Death Review Cmmittee Case Review Reprt N. 3 March 2018
Table f Cntents Incident...3 Backgrund...3 Systems Invlved...3 Key Findings...3 Best Practices...4 Recmmendatins...4
Incident In 2010, tw children were murdered during a curt-authrized, unsupervised weekend visit. Backgrund The parents f the children were in an n and ff-again cmmn-law relatinship fr mre than eight years. One parent was the primary caregiver, while the ther wrked (ften ut-f-twn) t supprt the family. During this time, there were cntinual disputes related t the custdy, access, supervisin, and parental discipline f the children. A number f parties were actively invlved with this family ver the years, including Children s Services, varius health care prfessinals and the judiciary. The fllwing cntext is prvided in supprt f the cmmittee s findings and recmmendatins: There was a lng-standing histry f mental health issues that raised cncerns, at times, fr the safety and well-being f the children. Challenges develped in terms f maintaining regular adherence t a medicatin regime aimed at treating these issues. Drug-seeking behaviur als develped. Multiple dctrs were visited at different medical centres in attempts t btain drugs, in additin t criminal behaviurs, such as theft and frgery. Varius health care prfessinals (family physicians, general practitiners and psychlgists) were invlved in the care and management f these mental health issues. Medicatins were prescribed, alng with ther nging supprts, such as cunselling and parenting classes. Interventin services were prvided in relatin t the children in the frm f apprehensin and custdy rders and regular meetings, assessments, a parenting plan and drp-in visits with casewrkers and family reunificatin wrkers. There were a number f curt applicatins related t this family and access t the children varied frm supervised access t unsupervised access. In the end, unsupervised access remained in place given the evidence befre the curt. Systems Invlved There were three key service prviders invlved with this family: Children s Services, Child and Family Services (CFS), Alberta Health and Justice and Slicitr General (the curts). Key Findings Families that d nt present as high-risk fr family vilence can be high-risk, as in this case. Independent evidence, such as infrmatin frm prfessinals, family members and clleagues, thse wh have the ability t reprt n client behaviur, rather than a client s selfreprting, is necessary t assess the risk f harm. CFS needs access t mre infrmatin fr critical decisin making, and t reduce CFS reliance n client self-reprting, which may nt be reliable, cmplete and timely. Prescriptin drug abuse and misuse was extensive in this case. Family Vilence Death Review Cmmittee alberta.ca March 2018 3
Individuals frequently accessed multiple medical prviders and services cncurrently, and are prescribed medicatins thrugh multiple surces. Currently, an individual s patient histry is nt mnitred by the treating physician at every pint-f-care t ensure that shared, cnsistent patient infrmatin is used t make infrmed medical decisins fr the safety and well-being f the individual. Best Practices All effrts were made t cnnect individuals wh required medical and mental health services with the prper resurces. CFS and service prvider effrts t de-escalate the relatinship between the children s parents by prviding services t help the cuple limit cntact with each ther; and, in situatins where cntact was necessary, t help facilitate and mediate cntact between the parents. CFS presentatin t the curts f knwn infrmatin cncerning family circumstances while the children were in care. Recmmendatins 1) Child and Family Services (CFS): T Children s Services, Child and Family Services (CFS), including all bdies which exercise authrity under the Child, Yuth and Family Enhancement Act in Alberta, the FVDRC recmmends: That n every Child Interventin case requiring a Safety Assessment, an actuarial risk assessment tl be used t assist with identifying ptential levels f risk and t determine if preventative safety measures and services are required. If the results f the actuarial assessment determines further interventin is required, then the fllwing checks be mandatry as standard practice: Criminal recrd checks n the family t applicable plice agencies (including bth lcal plice agencies and RCMP) t check fr cnvictins and fr current and past criminal charges; Curt system checks fr Prvincial Curt and Curt f Queen s Bench prtectin rders granted under Alberta s Prtectin Against Family Vilence Act, r restraining rders, peace bnds and ther curt rders that invlve the family; Alberta Health infrmatin checks n the family, such as Netcare infrmatin, including checks fr prescriptin drug abuse. It is als recmmended that the abve checks be redne and updated every time a significant change is made invlving parental and guardian cntact r access t a child, including: Any changes t visit supervisin, frequency, r duratin; Prir t filing applicatins fr rders, which cause a change in circumstance fr the children and befre a return t parental r family care is cnsidered. That CFS require drug testing t check fr parent and guardian cmpliance with therapeutic drug prescriptins as a standard practice, especially in cases where psychiatric medicatin is necessary fr parents and guardians t maintain their well-being. Family Vilence Death Review Cmmittee alberta.ca March 2018 4
That the use f the Screening Aid fr Family Vilence (SAFV) be discntinued, as it is nt an assessment tl and is nt predictive in nature. The SAFV nly identifies the existence f family vilence. It des nt address the level f vilence in the hme r generate recmmendatins fr safety. The FVDRC cmmends CFS n its Delegatin Training fr staff and recmmends that nging training at regular intervals be mandatry fr frnt-line staff. 2) Alberta s Legal System and the Judiciary: T Justice and Slicitr General, the FVDRC recmmends: The develpment r upgrading f sftware in the Prvincial Curt and Curt f Queen s Bench systems t: Allw the civil and criminal systems t share infrmatin and identify prceedings and rders, especially with cases invlving family vilence, custdy issues, and child prtectin cncerns between/amng the Prvincial Curt and Curt f Queen s Bench systems. In the absence f new systems r upgrades t current systems, it is recmmended that mandatry manual searches fr multiple prceedings and previus rders in all curt systems be cmpleted, and that a mandatry frmal infrmatin-sharing arrangement between curt systems be put in place, s that this infrmatin is prvided fr judicial cnsideratin in advance f prceedings. The widespread implementatin f integrated family vilence curts in Alberta, in cnsultatin with the Family Curt Intersectin Cmmittee regarding the implementatin f the integrated curts. 3) Alberta Health: T Alberta Health, Alberta Health Services, the Cllege f Physicians & Surgens f Alberta, the Cllege and Assciatin f Registered Nurses f Alberta and the Alberta Cllege f Pharmacists: That all authrized health care prviders, authrized infrmatin custdians and their authrized affiliates in Alberta wh have nt registered fr the Alberta Electrnic Health Recrd (Alberta EHR) via the Alberta Netcare nline prtal (hereafter referred t as Netcare ) be required t d s within a reasnable timeframe, and that enfrcement measures be intrduced t ensure registratin. That all authrized health care prviders, authrized infrmatin custdians and their authrized affiliates in Alberta be required t access patient prfiles via Netcare at every pint-f-care interactin with patients, t ensure patients situatins are assessed in the mst infrmed way pssible. That all authrized and designated drug prescribing bdies in Alberta be required t cnsult Netcare fr a patient s prescriptin histry infrmatin befre prescribing any drugs r medicatins. That all authrized and designated drug dispensing bdies in Alberta be required t cnsult Netcare fr a patient s prescriptin histry infrmatin befre filling any prescriptins fr drugs r medicatins. Family Vilence Death Review Cmmittee alberta.ca March 2018 5