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Samantha Martin Report Released
November 2, 2012 permalink
The full report on the death of Samantha Martin has been released by the province of Alberta. A news article is enclosed, links to the report and comments by fixcas are added to an earlier story.
More questions than answers in fatality inquiry report
A St. Albert family has more questions than answers after the findings of a fatality inquiry into their daughter’s death were released to the public Friday.
Samantha Martin died on Dec. 3, 2006, at the age of 13, coping with a rare genetic disorder called Tetrasomy 18p all her life. But the inquiry could not definitively determine whether seizures caused by that disorder, the care Samantha received in a foster home, or another factor was the ultimate cause of her death.
“I find that the manner of death was natural, and that the cause of death may well have been a seizure, but due to the absence of evidence, it is not possible to say that this was the probable cause of death,” wrote Judge Marilena Carminati in the fatality inquiry report.
The report also cites the testimony of former Alberta chief medical examiner Dr. Graeme Dowling, who told the inquiry that, in reviewing Samantha’s autopsy report, he did not have enough information to say precisely what happened, although he did say one possibility might be a seizure. The only other possibility Dowling gave any weight to was that impacted fecal material in Samantha’s bowel may have “rubbed away just the inner lining of the bowel, allowing bacteria to seep into the bloodstream, even though there was no perforation, leading to sepsis and death.”
Carminati goes on in the report to make several recommendations to prevent similar deaths, including:
- ensuring Children’s Services case workers overseeing foster children 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”;
- enhancing current policies to ensure foster children are receiving regular medical checkups and possible issues are not overlooked;
- ensuring processes are in place to follow up “in an effective and meaningful way” on medical concerns brought up from sources outside the family, like schools; and
- ensuring case workers have reasonable workloads so they have time to document and follow up on medical needs of foster children.
Samantha’s parents, Velvet and John Martin, received a copy of the inquiry’s findings a couple of weeks ago, before it was made public Friday, but Velvet said she felt there was nothing in the report that would have changed the situation Samantha was in or anything similar.
“All it’s underscoring is the fact that the policies that are in place, the judge has said you really need to do them. They haven’t been doing them all along so what it actually should say is there are repercussions if you don’t do your job,” Velvet told the Edmonton Sun. “I look at it and go, ‘OK, a lot of the truth is revealed but at the same token, nothing has been done.’”
Samantha Lauren Martin was born June 4, 1993. She was soon diagnosed with Tetrasomy 18p, a rare genetic condition in which the short arm of the 18th chromosome appears four times in body cells rather than just twice. Symptoms vary from case to case, but it can lead to abnormalities in the head and face, malformations of the spine, hands and feet, difficulty with motor skills and developmental delays, including limited speech and behaviour problems. Many patients also has gastrointestinal problems, but are usually not especially thin or frail.
When she was only seven weeks old, Velvet and John placed Samantha in foster care, believing she would get better care in a foster home than she could with them. Samantha was placed with the Himschoot family near Morinville.
When she was three years old, the Martins reinitiated contact with Samantha, and she eventually spent more time with her biological parents, leading to joint guardianship in October 2001 and Samantha moving back to St. Albert in June 2006.
Samantha was at the Martins’ home on Nov. 29, 2006, when she became ill, vomiting and suffering from diarrhea. As her condition worsened, she was taken to the Sturgeon Community Hospital, then to the Stollery Children’s Hospital. She was put on life support,but taken off a few days later.
“The fact that Samantha was on life support for a period of time contributed to the difficulty in assigning a cause to Samantha’s death,” Carmanati wrote in the inquiry report. “It is known that her heart stopped; much less clear is why it stopped.”
Before she died, though, there were red flags raised about Samantha’s treatment while in foster care. Velvet Martin testified to the inquiry that she had suffered numerous fractures and bruises, which caught the attention of staff at her school. Samantha did not speak, though, so it was unclear exactly how these injuries occurred.
Samantha also weighed only 49 pounds at the time she returned to live with the Martins, but gained almost 11 pounds in about a month afterwards. School staff reported that the foster family’s biological son often had “larger, more balanced lunches” than Samantha did, and when this concern was raised, the foster mother told the school to “fill Samantha up with water.”
As well, Samantha’s pediatrician, Dr. Lyle McGonigle, said in the inquiry report that he would normally see patients with conditions like Samantha’s once every months, but only saw Samantha roughly once a year.
Children’s Services case worker Lorna Huff, who handled Samantha’s case from 1997 to 2005, also testified at the inquiry that, after a meeting that included the foster mother in November 2002, concerns were raised by Samantha’s school that she may be suffering from seizures, and that her foster family consult with her doctor about having an encephalogram done.
But the inquiry report notes that Dr. McGonigle was never informed by the foster mother about the possibility of seizures or the need for an encephalogram.
Eventually, after moving back in the Martins, Samantha was taken for the necessary tests. One encephalogram conducted in October 2006 was inconclusive, while Samantha died before the results of another test a month later could be fully analyzed.
Huff was also supposed to have face-to-face visits with Samantha every three months, but the inquiry report notes that periods as long as 14 months went by without visits. Huff testified, though, that there she made two in-person visits during that period but did not document them. There were other lengthy gaps in the visitation history, but Huff told the inquiry that her case load made it difficult to keep up with paperwork.
Huff also relied heavily on Samantha’s foster family for information, the inquiry report notes, as the Himschoots had several medically fragile children placed their care over the years, and Huff was under the impression Samantha was seeing a doctor monthly.
Even after another social worker took over Samantha’s case, a 2005 Children’s Services review of the file found that no face-to-face visits had been documented between February and November 2005, and there was no indication of annual medical or dental checkups in the file.
While the inquiry report is little comfort for the Martins or the parents of other disabled children, the Alberta government is taking it seriously. It has been forwarded to the Human Services Minister Dave Hancock, whose department is reviewing it thoroughly.
“It’s never a good thing when someone passes away in care, regardless of the circumstances,” Human Services press secretary Craig Loewen told the Edmonton Sun. “There are some changes that have been made since that time.”
Loewen pointed to legislation passed in early 2012 that made the province’s child and youth advocate an independent entity, with the ability to investigate any case he or she chooses.
He added that more supports are available for families with disabled children, and that 95 to 98 per cent of disabled kids are able to remain with their biological families.
“That’s not to say that we can’t learn things from the fatality report,” Loewen said. “We’re certainly going to take a look at the recommendations. It’s something we definitely take seriously so there could be further changes.”
Source: St Albert Leader