Jury Rules Child's Death Was Homicide

By 250 News

       Prince George, B.C. - The Coroner’s jury in the death of  Savannah Hall,  has ruled the 3 year old’s death was  homicide.

The official  document says she died of  an "hypoxic Ischemic Brain Injury due to or as a consequence of a Cerebral Edema, due to  or as a consequence of suffocation."

In other words, the Jury did not accept the theory  that Savannah  had a  seizure, which  caused her to  vomit,  aspirate,  which cut off the  oyxgen to her brain, resulting in the  swelling of the brain .

In  making a classification on  death, the jury  had to make a choice between accidental, natural, suicide,  undetermined, or homicide.

The jury also made 26 recommendations, which  call for major changes within the Ministry of Children and Family Development, but  there are recommendations for  all who had  contact with  the child  through her life,  or   in  their attempts to save her life.

1. The Ministry of Children and Family Development (MCFD) improve their procedures relating to the recording and sharing of all information, relating to both substantiated and unsubstantiated allegations whch may  relate to the safety and welfare of children in care.
2. MCFD should develop and implement a single document  equivalent to the "Child Services Snapshot" which  records all agetations against a foster home.
3. MCFD should require that foster parents be reained in First Aid and CPR.
4. MCFD should revise and clarify the Standards for Foster homes as it relates to the use of both mechanical and physical retraints.  These standards should specifically require the approval of a physician prior to their non-emergent use.
5. MCFD should revise the Supervised CIsit and Transportation Record so as to require the signature of the visting natural parent and that a copy of the record is provided to the natural parent.
6. MCFD should require immediate  notification to the appliciable police agency of all serious incidents inveolving physicial injury to children in care.
7. MCFD should require that it be notified of all physician visits mae by children in care
8. MCFD should ensure the availability of social workers to promptly respond to and investigate allegations involving  potential harm  to a child in care in those situations in which the childès assigned social worker is unavailable.
9. MCFD should ensure that foster parents are provided with all available information regarding a child’s history within 72 hours of placement.
10. MCFD policies should require that all resources providing services to children in care immediately report to the MCFD and MCFD investigate, unusual periods of absence from the resource.
11. MCFD policies shouldrequire that after hours social workers have access to information relating to the proposed foster home,  Such information to include : number of children presently in care, the level of care provided  by  the foster home, and the history of allegations made against that foster home.
12. MCFD information management  systems should track all allegations made against a foster jhome, including those relationg to both  Quality of Care, and  Abuse or Neglect.
13. MCFD policies  should require  a medical  assessment  before placing a special needs child in care.
14. MCFD policies should require that  all social workers involved in the care of children in a foster home be provided with a copy of the Annual  Review of that foster home.
15. MCFD policies should require that all allegations of QUality  of Care and Abuse or Neglect be independently reviewed by workers that  are not involved in the management of the foster home, or the care of children placed within that home.
16. MCFD policies should  require that Guardianship workers visit each child in care on their caseload not less than twice yearly.
17. MCFD policies should require that the resource social worker review with each foster parent, at least once evey five years, the then applicable Standards for Foster Homes.
18. The BC Ambulance Service (BCAS should modify the form of its Crew Report to allow for extra room  for the recording narrative.
19. BCAS should  emphasize the requirement and  importance  of full charting of the Crew Report by all attendants.
20. The  City of Prince George Fire Department should require a full recording on its Fire Rescue and Safety Report of all significant scene circumstances when  responding to calls involving personal injury.
21. The Child Development Centre (CDC) should revise its procedures to improve reporting and communication with the MCFD regarding children in care
22. CDC should require notification to the MCFD of any unexplained absence of longer than two days of any child in care
23. CDC should  require the reporting to the MCFD of any observations of suspicious bruises on children in care
24. The College of Physicians  and Surgeons  should recommend to its members that they deliver to the MCFD copies of Consultation Reports relating to patients who are children in care.
25. The College of Physicians and Surgeons should recommend to its members that the patient history regarding children in care be taken  from other  health professionals and MCFD workers in addition to the history obtained from foster parents.
26. The Ministry of Health  should investigate the development of a website which  provides a central repository for medical information regarding children in care.

The jury delivered   the recommendations  after 9 hours of deliberation which followed  10 days of testimony from  nearly 30 witnesses.

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