Savannah Hall Inquest Resumes, More Questions Raised

By 250 News

  Prince George, B.C. - The Coroner’s inquest into the death of 3 year old Savannah Hall resumes today. While Coroner Scott Fleming is the one hearing this case, it was his colleague, Coroner Beth Larcombe, who first looked into the death of Savannah Hall.

(At left, Savannah Hall in the arms of her mother, Corinna Hall at the Prince George Library, two months before her death, photo courtesy Corinna Hall)

On March 26^th, 2002  ( more  than a year after Savannah’s death) Coroner Larcombe wrote to Dr. Glenn Taylor, the Pathologist at BC Children’s Hospital who conducted the autopsy on Savannah, asking Dr. Taylor to re consider his findings in Savannah’s death.   Larcombe wrote ; "I would like you to review this new information to see if there is cause for you to reconsider your original findings."

In the letter (received through a Freedom of Information request) Coroner Beth Larcombe said she had new evidence. She said “It is now known that the foster family that Savannah lived with was under investigation by the Ministry of Children and Families at the time of her death. The investigation was looking into allegations of abuse and neglect.”  This statement is a little stretched as  the family  was scheduled for investigation but in fact,  testimony  last week at the Coroner’s inquest,  said the investigation  had not  yet been started because of  staff shortages, and  in  fact,  6 children had been  placed in the Keene home  just  three weeks  before Savannah was rushed to hospital. 

The allegations made by Coroner Larcombe also said the Ministry had concluded its investigation “and have verified that there was maltreatment of the children in that home. That includes Savannah.” 

Larcombe goes on to point out that two other children were still in the home and the courts had allowed the children to stay there. “One of the two children is of particular concern to the social workers” writes Larcombe.

As a matter of record, the natural mother of one of the children Larcombe refers to , sought a successful order from the courts that would allow her child, to remain in the Keene home. If there were, as Coroner Larcombe writes, verified “maltreatment of the children,”  it is difficult to understand how the Court would allow the children to stay in the care of the Keene family.  One of the two children Coroner Larcombe refers to was 18 months old at the time and has remained in that home since that date.

According to the police reports obtained by Opinion250, Corporal Tracy Hardy of the RCMP Serious Crime Section writes that Dr. Taylor had done a post mortem exam and his results indicate the underlying pathology was a heart condition. Cpl Hardy writes; “Dr. Taylor was unable to come up with any alternate explanations for the child’s death, but that Myocarditis could be a very sudden event and was responsible for her collapse". That letter is dated June 20^th,  2001 fully nine months before Coroner Larcombe writes the printed letter.

As to the RCMP investigation at the autopsy on January 29^th 2001, the Pathologist writes ” of particular note is all the suspected bruising on the back, buttox and rib area, all turned out to be Mongolian marks not bruises”.

Coroner Larcombe writes again, “a huge shortfall in my opinion was the fact that there was not a satisfactory scene investigation”.

The Coroner fails to mention that the family took and placed every article of clothing and other objects into a special bin for police to examine. The family did clean up the home because the child had been throwing up, and there were lots of  people in the home at the time. Towards the end of December 2000, six new children were placed in the Keene home.  There was no effort made to hide any articles.

Coroner Lacombe writes, “Savannah’s social worker had no idea a restraint was being used, nor had the Ministry approved it”.  We now know that is not true.  Ministry of Children and Families employees have already testified the Ministry was aware of it, and the use had been approved by the Ministry.  The case worker was informed and agreed to the device after she had been told the little girl had broken two cribs with her violent thrashing and there was fear she could seriously injure herself if she broke a crib and sharp objects were exposed.

Was that information communicated to Coroner Larcombe?  If not, why not?

Coroner Larcombe writes to Dr. Taylor ; “In subsequent requests the foster parents have refused to respond to any questions, on the advice of their lawyer”. According to records, the Keene family met at least 8 times with Ministry staff during which the conservation was taped and transcribed. The Keene’s hired a lawyer and had him appear with them after Ministry staff suggested maltreatment of children in the Keene’s care without ever wanting to identify or be specific with the allegations.

In her final paragraph Coroner Larcombe wrote, “I would appreciate if you could take the time to review this information and then contact me with your opinion.”

Coroner Lacombe’s opinion has been adequately expressed in her letter. Dr Glenn Taylor writes a new report.

Here is what we know to be fact:

• The Pathologist had examined the child’s body and determined the probable cause of death to be a collapse caused by myocarditis, leading to cerebral edema.
• The RCMP had conducted their own investigation and submitted a report in which Dr. Taylor said he was unable to come up with any alternate explanation of the child’s death
• The RCMP and Dr. Taylor both say the suspected bruising turned out to be Mongolian marks.
• Dr. Taylor has  revised his report and now says  he is not certain  if Savannah died with myocarditis, or from myocarditis.

Here is what we don’t know:

• Why, 10 months after the death of Savannah, did Coroner Beth Larcombe choose to write to Dr Taylor to change his findings in the matter?
• Why after writing a letter in which she outlined reasons why she felt Dr Taylor should re examine his findings, did she not seek an inquest into the death of Savannah?
• Who was it that told Coroner Larcombe to make such statements as she had in her letter to Dr Taylor?
• Why is it that the only person calling for an inquest was the foster mother Pat Keene, when she learned  she was  under investigation?
• Who determined that no inquest would be held and why is there one underway now.6 years after the matter?

Finally,  and probably one of the most  puzzling questions :  Why wasn’t Coroner Larcombe called to testify at the Coroner’ inquest into the part she played in the investigation?

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