INQUEST REPORT TAKES AIM AT CHILD WELFARE, JUSTICE SYSTEM
Winnipeg Free Press March 13,
2004, Reported by Mike McIntyre
Girl's death -- society's failure
A Manitoba Judge-haunted by images of 23-month-old Nadine Beaulieu's battered, emaciated body-has issued a stinging report into society's failure to protect the little girl from a gruesome death.
The 200-page inquest report raises alarming questions about Child and Family Services and the failure of the justice system to bring Nadine's killer to justice.
And in a remarkable move, provincial court Judge Roger Gregoire
has suggested CFS consider naming one of its facilities in honour of Nadine "to
serve as a reminder to all those who work in child welfare to be ever vigilant
in order to prevent this type of tragedy."
NO TRAINING
Nadine died February 21, 1996 in Winnipegosis, about 270 kilometers north of Winnipeg, after being placed in foster care by West Region CFS in the nearby Pine Cree Reserve, population 800.
The foster parents had no training, weren't properly screened
for criminal records and were improperly supervised by an overworked CFS
employee, Gregoire has found.
Residents on the reserve were aware of problems and concerns with Nadine's
health and her foster parents-including their criminal history-but took little
action to report it to authorities, he said.
"On many occasions...as I viewed the very disturbing photos of
the poor little emaciated and battered body that lay upon the autopsy table, I
questioned whether Nadine's life was sacrificed on the alter of social
expediency in society's rush to attempt to correct the social wrongs of past
generations," wrote Gregoire.
An autopsy revealed Nadine's cause of death as "the application of force by an
adult person to her abdomen," which caused a rupture and internal poisoning.
"It appears she was struck with tremendous force. Her death was
by no means sudden. It would have taken many hours for the digestive juices and
partially digested food to seep out into her abdomen, causing the infection
which killed her," said Gregoire.
There were numerous other signs of abuse on Nadine, including at least 75 recent
bruises on her face, scalp, chest walls, lower abdomen, back, buttocks and
extremities, scattered roundish scars and small abrasions; inter-abdominal
bruising on her stomach wall and connective tissue on the pancreas; and
dehydration, including sunken eyes and dry skin.
She was also severely undernourished, with the ribs clearly evident and her
buttocks emaciated. And there was evidence of a broken right pelvis and three
broken ribs, both of which were healing at the time of her death.
Despite the abuse suffered by Nadine, no one has ever been held responsible for
her death.
Nadine's foster parents, Clifford and Laura Richar, were charged with
manslaughter and failing to provide necessities of life, but the case was thrown
out of court because of RCMP mistakes in obtaining a statement from the accused.
In a statement to police, Clifford Richard, 33, had told investigators he hit
Nadine in the stomach with a backhanded swing of his arm because he was angry
she kept trying to get some fried chicken.
The Richards both testified at the inquest and maintained they did nothing
wrong.
But the judge said Clifford Richard's testimony lacked credibility and he often
changed his story.
"It was difficult to believe him on much of what he says," said Gregoire.
"I cannot say with any degree of certainty that he is the one who inflicted the
blows that killed Nadine; however, I am left with the distinct impression that I
was not getting the entire truth from Mr. Richard and he knows more than he is
telling the court," said Gregoire.
Richard testified that Nadine was a "handful." As a possible explanation for
Nadine's injuries, he claimed Nadine was running up and down stairs and may have
injured herself.
Hours later, she began vomiting. Richard said the illness continued through the
night, and was worse by morning. He told his wife to give her a bath while he
called a cab.
Richard claims he gave Nadine CPR in the cab, and that she was "rubbery" but
breathing. He also claimed Nadine hit her head on the cab as he took her inside,
but denied hitting or kicking her in the stomach.
Richard also claims Nadine fell out of the top bunk of her bed and struck the
floor two weeks before her death. He never took her to a doctor, even through
she was walking in an unusual way afterward. Nadine also fell twice the day
before her death, and was jumped on by some other children while play fighting,
he said.
The province's chief medical examiner called an inquest after criminal charges
were stayed against her foster parents. The inquest began September 24, 2001,
and ended March 5, 2003. In total, there were 43 days of evidence, during which
46 witnesses testified.
Gregoire said the inquest was "a quest for answers, but unfortunately, many
questions remained unanswered."
"Unfortunately...I am unable to come to any definite conclusion as to who was
the individual who inflicted the blows which led to Nadine's death. I was left
with an uncomfortable that there is an attempt to cover up exactly what happened
by the person or persons involved and by those who have knowledge of what
occurred," said Gregoire.
"Nadine deserved to have her short life and death carefully scrutinized in order
to determine as far as possible what happened, why it happened and what could
have been done to prevent her death."
Gregoire has made 71 recommendations for change, many of them aimed directly at
CFS (Child and Family Services)
"For the loss of life there can be no scapegoats. All of society has to accept
and share some of the responsibility for her untimely death and collectively
move forward toward a time when children can truly be safe in our communities."
Nadine's family history is filled with tragedy. Her mother was born in 1974 into
an abusive family and was quickly seized by CFS. She was 20 years old when she
had Nadine, her third child. Four more quickly followed.
The woman is an alcoholic and has lost all seven children to CFS.
Nadine's birth father has a lengthy history of child abuse, both as a victim and
offender. He has a lengthy criminal record, including a bugger conviction
against a child.
TURBULENT LIVES
Both parents-who can't be named under a court order-led turbulent lives filled
with violence, abuse and poverty. They moved throughout Manitoba, and the
children were often left with relatives while they partied.
Nadine and her two siblings at the time were eventually apprehended and placed
with the Richards, who had two children of their own. The couple was paid $37.00
a day per child.
Clifford and Laura Richard had recent criminal records for assault and drunk
driving, but that information was never disclosed to CFS. When it was eventually
discovered during criminal record checks, the foster children were already in
their care and not removed.
"It appears there was a certain willingness on the part of the agency to bend
the rules somewhat in order to obtain foster homes," said Gregoire.
"This is unfortunate as had the agency followed its own policies in regards to
foster home licensing, the Richard home would not have been approved."
Agency workers also didn't realize the toddler likely suffered from fetal
alcohol syndrome, despite numerous "red flags" related to her behaviour.
Glennis Mousseau, the CFS worker responsible for Nadine, has been on an extended
stress leave since 2001. She testified her caseload involved 50 children and 30
other family files. She trained in-house by CFS, but had no formal or university
training.
Wayne Govereau, the children's advocate in Manitoba at the time of Nadine's
death, was critical of CFS for failing to properly document their visits to the
girl's home and provide information about her care.
Only Mousseau and a second CFS worker ever visited the home. They described a
girl who had "high needs," was developmentally delayed and would often gorge on
food, the sign of a deprived child.
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Here are the key recommendations from the inquest:
All child-care workers, health-care workers, teachers and day-care workers
should be given mandatory education and training in fetal alcohol syndrome (FAS)
and its effects to assist them in recognizing children who are suffering.
Parents and foster parents of FAS children should receive ongoing training and
support.
Where a child-caring agency is aware that a mother has a history of alcohol use
during pregnancy, a mandatory FAS assessment should be done to ensure early
diagnosis, intervention and support.
If one child is found to be suffering FAS, other biological children of the same
mother should be assessed.
The provincial government should consider legislation to protect fetuses from
the effects of substance abuse.
Specifically trained home-care aides should regularly visit newly licensed
foster parents caring for preschool children for the purposes of interacting
with these children.
CFS workers should make it clear to all foster parents they have the right to
request a child be removed from their home.
West region CFS (this is the agency Nadine was under) should drastically upgrade
their training of all front line and supervisory staff.
West region CFS should reinforce with their social workers the importance of
maintaining detailed recording and notes.
West region CFS will ensure reasonable caseload limits are reduced from the
numbers at the time of Nadine's death.
The College of Physicians and Surgeons of Manitoba should provide further notice
to all of its members about the prevalence of FAS on society and make them aware
of an FAS clinic that can assess children.
The province should engage in a promotional campaign in aboriginal communities
to make all members aware of their responsibility to report suspected child
abuse.
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Source:
Winnipeg Free Press March 13, 2004
You can email the reporter, Mike McIntyre at
mike.mcintyre@freepress.mb.ca
and letters to the editor at
letters@freepress.mb.ca