STC Root Cause Analysis Regarding Passing of STC member Infant Root Cause Analysis is a useful process for creating a better understanding of an occurrence. Identify what negative event occurred. Then, look at the complex systems around that event, and identify key points requiring attention. Finally, determine solutions to address those key points, or root causes.
Foreword To First Nations there is no greater sacred duty than the care and well-being of our children; in their flourishing, hope and as a legacy for our future as Peoples and Nations. STC member First Nations bear witness every day to the legacy of residential schools, the 60 s Scoop and continuing colonizing and paternalistic policies. This has left lasting intergenerational impacts in our communities leaving too many children and families to struggle with a loss of childhood, a loss of parenting skills, addictions and devastating levels of poverty. Despite these challenges, there are many positives emerging within our communities, demonstrated by our ongoing resiliency and the continuing survival of our culture(s). To this legacy, STC First Nations use the tools and resources available to them to carry out their sacred duty and obligations. One of these tools is the Child Welfare system; a complex set of rules, regulations, court appearances and often judgements. It is further complicated by the demands of massive systems of control such as provincial ministries and federal government departments. The balance between the traditional and western approaches is challenging. The duty of our Leaders is to examine the many paths, options and directions available to ensure action, both administrative and political, is consistent with their authority and aligned with exercising, and thereby protecting, the Nations jurisdiction over their children and families. STC Leaders have directed that we administratively occupy the field of child welfare through resources available from the federal government for that purpose and in collaboration, through the extent required in the terms and conditions of the Bilateral Accord (1996); and at times, with other parties. This required the institution of a system of service delivery, over-sight, review, evaluation and when inevitably required, inquiry. Part of this system was to seek independent, third party review and evaluation. After several years of preparation STC Health & Family Services Inc. was Accredited with Commendation in December 2014. Required in this is a system of continuous quality improvement (QI). QI calls for the establishment of a process or processes by which the cause or circumstances surrounding a sentinel event can be examined and improvements implemented. The above then provides the context for this report. Although the cause of the infant death was ascertained as an undiagnosed medical condition the need to examine how the wholistic system functioned to support the child and the family required the Root Cause Analysis because of the gravity of the event. The loss of a child under any circumstances is devastating for a First Nation; for a parent, the grief remains immeasurable. Unfortunately, the reality is that as difficult as it may be, service providers and systems are most open to change process, procedures and work habits. The intent is to improve the existing systems through the change of organizational structure, by amending policy, procedures and clarifying ambiguities, all in the interest of maximizing positive contributions and avoiding negative ones. 1 P a g e
Purpose The purpose of the root cause analysis is not to assign blame but attempts to identify cause, if any, and contributing factors which may have influenced the event. The root cause analysis contains recommendations or corrective measures intended to address any short falls identified and ensure better outcomes in the future. It is part of the continuing quality improvement/quality assurance; accountability and transparency to the STC members. The purpose of this report is threefold: one purpose is to fulfill the Saskatoon Tribal Council s commitment to providing exceptional program and service delivery for our members by utilizing the recommendations as a guide for change. Two is to acknowledge responsibility to examine and question the event and its surrounding circumstances under the authority and jurisdiction of the STC First Nations. Third, to publish and circulate the findings as a mechanism of accountability to the STC membership we serve. Respectfully, it is to that authority to which we are held to account, and as such, it is to that authority we must first report. Background The following report is a root cause analysis stemming from a Sentinel Event which occurred within one the seven (7) member communities of STC. The intent is to outline areas of operation risk (where inaction could lead to repeat); however there may be other considerations for risk determined by STC Leadership as a result of the root cause analysis findings and recommendations. It becomes an important part of accounting for what and how things are being done with an eye to risk management within the overall quality improvement process. A root cause analysis was initiated to identify potential future risks and to ensure compliance both within the accreditation process and accountability to STC member citizens. It is part of the quality assurance process and will lead to systemic changes to ensure improvement in systems that support service delivery. Root cause analysis assumes that systems and events are interrelated. An action in one area triggers an action in another, and another and so on. By tracing back these actions, you can discover where potential problems may begin and how it may grow to manifest into a more pronounced symptom. Usually there are three basic types of cause to events: 1. Physical causes-tangible, material items failed in some way. 2. Human causes-people did something wrong or did not do something that was needed. Human causes typically lead to physical causes (for example, accidents). 3. Organizational Causes- A system, process or policy that people use to make decisions or do their work is faulty. 2 P a g e
Root Cause Analysis looks at all three types of causes. It involves investigating the patterns of negative effects, finding hidden flaws in the system and discovering specific actions that contributed to the problem. Event Description The circumstances of the Sentinel Event involved the sudden death of an STC infant on reserve; within one of the seven (7) STC member First Nation Communities. The Infant at the center of this report was one of twins, born premature on August 7, 2015 at Royal University Hospital in Saskatoon. The information reviewed reflects that the infant was born prematurely at approximately 33 weeks gestation. They were born into a large and complicated family system at the time of the birth; the infant had seven (7) siblings who ranged in age from 12 years to 11months old. On October 25, 2016; the RCMP reported that the infant was found to be unresponsive in their home. Upon transport to the hospital and subsequent to further examination, medical professionals later deemed the cause of death to have been stemming from complications of a health condition. At the time of the infants passing, there was lack of clarity around whether the family was receiving mandated services in accordance with legislated obligations via STC Child and Family Services. As such, the STC General Manager of Health and Family Services Inc. was notified and immediately moved to preserve the file documentation. Upon review of the file information it had been determined that no mandatory services had been provided by STC Child and Family Services Inc.; though the family was in receipt of and supported by voluntary community services. Chronology of Events/Timeline (Mandatory Services) January 23, 2015 One intake report was received regarding a concern and upon attendance deemed the concern invalid. On May 16, 2015-830pm One intake report was received regarding a concern. The intake did not involve the family home nor were other family members involved. The youth involved in the concern was temporarily placed with extended family in a private arrangement and subsequently returned to the family home. October 10, 2015 One intake report received a report from the RCMP. The intake was documented at 1:39 pm; the RCMP attended the home at 2:34pm. The RCMP verified that the concern was not valid; Child and Family Services deemed the intake unsubstantiated. On October 25, 2015-5:59 pm One intake received from the R.C.M.P. concerning the sudden death of an infant. The R.C.M.P report indicated that there were no indications of foul play and no investigation would occur. 3 P a g e
Inquiry and Method The need for this Root Cause Analysis was determined by the General Manager of Health and Family Services Inc. who oversees programs within both community health and child and family services programs. This Root Cause Analysis used case file information specific to STC Child and Family Services. Once the findings and root cause(s) were determined, corrective actions were identified; this analysis will be communicated to the STC Leadership team. The purpose of this is to inform the leadership team of corrective actions, planned changes, and ongoing risks and gaps in service delivery as a whole and to enhance communication of the ongoing implementation of planned changes to the appropriate personnel once the recommendations are approved. This will also serve as a lessons-learned and be used to improve services. Findings and Root Cause Based on the conclusions for the Sentinel Event on October 25, 2015, the root cause analysis has determined that though the infant was not in care, community services were being provided to the family of the infant subject of this report; the infant remained in the care of its parents. Further, that although there was no clear legislative base to take the child or children into care, there was awareness that the family required and received community services. It is the delivery and intersection of those supports and services which were subject to the organization portion of the Root Cause Analysis. The micro level analysis of the role of STC Child and Family Services has demonstrated that legislated obligations were fulfilled. The larger macro level system examination which is a part of a higher standard of service delivery was deemed necessary to fulfil the STC commitment to it member citizens to operate with transparency and accountability. This macro level analysis identified several overarching organizational risks which require immediate remedy as part of the quality assurance (QA) and/or quality improvement (QI) processes. 1) That, STC Health and Family Services Inc. immediately embark on a comprehensive structural review of the Child and Family Services Program to ensure that client centred services are being provided and that legislated obligations are maintained. Further, that as part of this restructure that a mechanism of oversight be immediately implemented based on empirical evidence. 2) That STC Health and Family Services Inc. take immediate action to clearly define processes and procedure of collaboration across all programs to ensure compliance and consistency in service delivery. 4 P a g e
Corrective Action Based on the findings of the sentinel event on October 25, 2015 the Root Cause Analysis (RCA) has determined the following corrective action to prevent a repeat of this incident: 1) That STC Child and Family Services has been significantly removed from its original mandate and principles and requires restructuring to ensure the organization aligns with the approved mandate and principles. Overall, in the restructuring of Child and Family Service, there needs to be a renewed focus on documentation, training and compliance oversight to ensure fairness and consistency with organizational principles focused on service excellence. Recently, a new position was implemented within Health and Family Services to provide a renewed focus on compliance and practice. The new position has been tasked with reviewing compliance performance and making recommendations to structural changes to increase oversight and promote practice fairness within Child and Family Services. The restructuring of child and family services will see increased support positioned within communities and the creation of a new unit within child and family service which will focus on reintegration and community development. Two child protection workers have been hired while an additional four positions are in the selection process. The restructure will see an additional position within the Child and Family Services to assist the Executive Director as an Assistant Program Director to ensure increased oversight. 2) That STC Health and Family Services Inc. examine its processes for collaboration between all internal programs to ensure client centered services; and, that as part of the process of collaboration that a renewed emphasis on community development commence in order to ensure consistency of services across the system overall. Child and Family Services Supervisors have been reorganized to actively participate in the Team Leads monthly meetings. The Team Leads are clinical supervisors within Health and Family Services Inc. who provide support and advice to their assigned community counterparts and staff. Team Lead meetings are intended to promote collaboration and communication at the Supervisory levels. The Teams Leads aid in planning and identifying opportunities for community development in a coordinated manner. Clinical Supervisors have also been tasked with reviewing and revising policy and forms for system wide consistency. In this response, the movement to a more client centered case management approach will provide the basis for enabling clients or service providers to discuss all aspects of a file with client consent and involvement based on evidence. 3) That STC Child and Family Service ensure that all STC programs are aware of Duty to Report and other legislated obligations are clearly communicated. As part of the STC onboarding components, the Duty to Report and other legislated obligations are provided to all staff upon commencing employment with STC. Further the Duty to Report is 5 P a g e
provided to communities as requested via personal presentation from the Child and Family Services Program as well as provided in onboarding materials to new community portfolio counsellors new to the Child and Family Services portfolio. 4) That STC Health and Family Services Inc. ensure that all employees are in compliance with STC Policies and Procedures, especially where there may be concerns of confidentiality attached to ensure that STC members are afforded a continued expectation of professionalism and confidentially in services. Further that Policies and Procedures have an established means of update and review regularly. As part of the ongoing Accreditation process, the established system of reporting is now being utilized to receive and track occurrences which include policy and confidentiality breaches throughout the STC Health and Family Services system. The occurrence reporting system is continually being refined to ensure that occurrences are being addressed and remedied as they are received as part of the ongoing overall quality improvement process. 5) That STC Health and Family Services Inc. clearly define lines of authorities within all programs to clearly articulate Role and Responsibility s where multiple programs may have involvement with one family. The Team Leads have been tasked with coordinating and facilitating services in community to ensure that a process meaningful to the family is utilized in providing services. This ensures that during the case conference process that the client/family is able to identify their main staff supports to act as their Case Manager to reduce the number or people families are coming into contact or communicating with to reduce confusion. The Teams Leads have been refocused to ensure that a process to clearly articulate how multiple roles and obligations (both professional and moral) occurs and is understood by not only the client but provides more defined boundaries for professionals who have some personal involvement in a particular case. This is intended to ensure that personal and professional boundaries are maintained in any arising issues, such as confidentiality; and those holding such positions are directed and supported in the continuation of service excellence. This process is at the beginning of implementation and will continue on an ongoing basis. 6) That STC Health and Family Services Inc. ensure that there is a mechanism in place to provide a centralized tracking system with the ability to reflect all services as a means of oversight and administration for complex files with numerous service providers. Research is ongoing to determine if there is an existing centralized case management system available and which is not cost prohibitive to meet the needs of STC members. 6 P a g e
The expected result of this corrective action is to ensure that all programs and services attached to, and who may coordinate with, STC Health and Family Services Inc. may provide better integration and education of both mandated and voluntary services provided to STC members regardless of the location where they may be in receipt of services. Conclusion This root cause analysis has demonstrated that legislated obligations were fulfilled. Although no amount of services may have prevented the infant from passing, we are obligated to pause during these difficult times to examine and refocus our services, to take every opportunity possible to ensure services are beneficial to every family who requests or requires services. 7 P a g e