Samantha Martin Report

October 19, 2012 permalink

The province of Alberta has produced a report on the death of Samantha Martin, a girl born with a genetic defect and returned to her mother at age 13. After years of malnutrition in foster care she had half the normal body weight for her age. She gained weight rapidly at home, but died of heart failure a few months later. The province has returned a verdict of death by natural causes, excusing itself of responsibility. But the report contains the usual suggestions that the social services system should do more.

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Fatality report documents failures in foster care system

By Elise Stolte, Edmonton Journal October 18, 2012 8:02 PM

A new fatality report makes it clear Samantha Martin died after years of suboptimal care and a lack of medical attention while in foster care.

Photograph by: Supplied, Velvet Martin

EDMONTON - Samantha Martin weighed 51 pounds when she was 12, half the average weight for a girl that age.

When school officials phoned her foster mother to ask why Samantha’s lunches were not as “balanced” as those of her own son, they were told to “fill Samantha up with water,” according to a fatality inquiry report released to the media by the family Thursday.

The medically fragile child, who couldn’t speak because of a genetic disorder, died at age 13 after spending most of her life in foster care. Her parents fought for years to get a fatality inquiry, and although Judge Marilena Carminati found the child died from natural causes, her report demonstrates failures within Children’s Services.

The report also makes several basic recommendations for Children’s Services, including that caseworkers have an accurate understanding about the disabilities of children in their care. She recommends Children’s Services keep a diary for each child to ensure children actually get the annual medical checkup as required, that concerns from reliable sources are flagged and followed up on, and that caseworkers have reasonable caseloads.

“All (the report) is really saying is they should be doing their job,” said Velvet Martin, Samantha’s mother.

She gave Samantha up at seven weeks, believing that with her daughter’s diagnosis of Tetrasomy 18p, putting her in provincial care was the only way to get her the support she needed.

Martin became involved in Samantha’s life again when she was three, and increased her visits from then on.

Samantha went back to live with her parents just after her 13th birthday, and quickly gained 10 pounds. But five months later she came home from school one day retching and quickly went downhill, dying in a hospital a few days later when her parents took her off life support.

Human Services Minister Dave Hancock was unavailable to respond to the recommendations Thursday, and a spokesman for his department said he had not yet seen the report.

The report is dated Oct. 2, but is not scheduled to be publicly released by Alberta Justice until Nov. 2. Samantha’s mother sent it to the Journal on Thursday.

The report outlines large gaps in Samantha’s medical care.

Samantha’s pediatrician testified that normally a child with Samantha’s condition would come to see him every three months. He saw her only four times between 2000 and 2004.

The pediatrician also testified Samantha’s genetic disorder would not have made her underweight, that would be a result of a low caloric intake.

Samantha’s case worker from 1998 to 2005 was required to have in person visits with Samantha at lease once every three months. But there was a 14-month gap with no visits at all, and other gaps of seven or eight months at a time.

The previous caseworker also had only three visits during a 26-month period, when there should have been eight or nine, and when the third caseworker took over she did not visit Samantha between February and November.

The first caseworker met with Samantha’s teachers, who suggested Samantha might be having seizures and should get an electroencephalogram or brain scan. She starred that recommendation in her notes, but did not follow up.

The only records from Samantha’s next doctor’s visit are about a prescription for Resperidal, a drug for behavioural issues that has nothing to do with seizures.

The caseworker testified she assumed Samantha’s foster mother would have told the pediatrician about seizure concerns, even though the foster mother wasn’t at that meeting. The caseworker said she thought Samantha was having monthly doctor’s visits, but none were recorded. In fact, at one point records suggest Samantha didn’t see a pediatrician or family doctor for three years.

By late 2005, school officials were complaining about unexplained scratches and bruises on Samantha, her low weight and poor lunches.

Children’s Services special investigator Natasha Dancause reviewed the file and spoke with caseworkers. But she did not meet with Samantha or talk with any of the doctors involved, nor did she note the lack of records for medical checkups in the files.

Dancause decided in February 2006 that no investigation was warranted.

As a foster child, Samantha can only be named in public because her mother fought to get the publication ban lifted in the early days of the fatality inquiry.

estolte@edmontonjournal.com twitter.com/estolte

Source: Edmonton Journal

The CBC story is Alberta girl, 13, failed by foster care, inquiry finds. Pat Niagara captured the CBC video (mp4).

Addendum: On November 2, the full report was released, available from the Province of Alberta or our local Public Fatality Inquiry (pdf). The report details Samantha Martin's years of neglect at the hands of the Alberta foster care system, acknowledging that her low weight was from malnutrition, not from her genetic condition. But the neglect is excused as contributing factor in her death on page 4:

However, Dr. McGonigle felt that Samantha’s underweight status which lasted for some years would not have been a contributing factor in her death, because when Samantha was returned to her biological mother and gained a healthy amount of weight, that would have countered any problems that would otherwise have been caused by the previous low weight. The autopsy report indicates that Samantha weighed 42 kg and was 1.42 m tall at the time of her death. Dr. Dowling, the pathologist, also testified that the fact that Samantha weighed far less than she should have for a considerable length of time was not a factor he could connect to her death in light of the other difficulties establishing a cause of death. Accordingly, it does not appear from the evidence that Samantha’s underweight years were a contributing factor in her death.

Ramarkably for a report of this kind, it names the persons responsible for Samantha's maltreatment. She was placed in the care of the (Mrs Joanie) Himschoot family near Morinville Alberta. Social workers were caseworkers Mrs Lorna Huff and Valerie Jensen, reviewer Diane Martin, and specialized investigator with Children’s Services Natasha Dancause [Kowalsky]. There is no mention of disciplinary action against any of these persons.

The report concludes with four recommendations:

• That Children’s Services should ensure that those caseworkers who work with a foster child have accurate and up to date information from a reliable medical source about the child’s disability and in particular, the impact, if any, of the disability on the health, weight, and fragility of the child. This needs to be well understood in order for the worker to make informed assessments about how the child is doing in care, especially in the case of a nonverbal child who cannot communicate concerns with the child’s worker.
• That Children’s Services should look at enhancing current policies to ensure that children are actually receiving their annual medical checkups as required, including a diary system so that the issue is flagged and not inadvertently overlooked.
• That where a recommendation comes from a reliable source (such as a school assessment) that a doctor examine the child for a possible medical issue that the child may be experiencing, that processes are in place to ensure the issue is flagged for follow up by Children’s Services in an effective and meaningful way, including required entry by the Children’s Services child care worker or other support staff at Children’s Services into a diary system.
• Ensure that caseworkers for the child have a reasonable case load so that they have the time they need to be able to adequately document and follow-up on medical needs of the child.

Samantha died after her genetic problems were aggravated by years of malnutrition. None of the recommendations would have contributed to saving her. The last, reasonable case load for caseworkers, is union-speak for hire more staff. The one factor that could have helped Samantha is not mentioned — provide for more control by the real parents. Had Samantha been fed by her mother for thirteen years instead of six months, the malnutrition would never have developed.