Canada's Auditor General unequivocally condemned the Northwest Territories' child and family services, again, in a report published on Tuesday.
Examining the territory's child protection services for the second time in four years, the Auditor General's office – which had been deeply critical of what it found in 2014 – said simply: things got worse.
Social workers lost contact with almost nine in every 10 children placed in foster care, didn't carefully screen where children were placed, and frequently failed to take basic steps like consulting criminal record checks, the report alleged.
The department made mostly administrative changes that didn't work and weren't properly resourced, appointed senior staff who didn't have the right experience, and sometimes did not know what front-line staff were doing.
"We determined that many of the services provided to children and families in the Northwest Territories that we examined were in fact worse than when we examined them in 2014," Glenn Wheeler, who led the audit, said in a statement.
"We are deeply concerned by the findings," Wheeler continued. "Children will remain at risk until [the territory's health department and related authorities] make the changes they said were critical, and that they committed to making."
At a glance: what the report said
- Many services provided to children and families got worse between 2014 and 2018;
- Foster homes and guardians were often inadequately screened and monitored, if at all;
- Rarely were social workers in regular contact with children, as they should have been;
- At least once, senior staff had no idea how front-line social workers were handling cases;
- Other senior staff weren't appropriately qualified and couldn't access the right database;
- Children ended up moving between foster homes twelve times on average; and
- The territory made big changes to a system that was already struggling, which didn't help.
These issues are discussed in more detail below.
In full: Read the Auditor General's report
In response, the territorial government agreed with all 11 main recommendations the audit put forward – and promised a raft of changes would be implemented.
The Auditor General's office, which independently audits federal and territorial government operations, delivered its extraordinarily blunt remarks in the same month that the territory released its own, less critical, annual report on child and family services.
The territory's own report, issued earlier in October, celebrated the fact that over a 10-year span, "more children and youth receiving services are remaining in the care of their parents, while the proportion of children being removed from their homes and communities is decreasing."
The NWT's report went on to admit its own, internal, audit had found "a low rate of compliance" in many areas, adding "immediate steps are being taken in order to improve the quality of services."
However, the Auditor General's report essentially said: we've heard it all before.
"Since 2014, the Department of Health and Social Services has been focused on changing its processes without sufficiently considering the impact of introducing complex changes into an already overburdened system," a summary of the Auditor General's report read.
"The audit found that many of the changes examined were not well implemented or resourced, and produced worse services for children and their families.
"Despite multiple commitments to do so, the department still has not assessed whether the financial and human resource levels it allocates to authorities are enough to deliver the required services for children and families."
Health and Social Services Minister Glen Abernethy, addressing reporters following the audit's publication, said his department was already working to address many of the issues raised and would "double its efforts."
Cabin Radio will carry the minister's response in full on Wednesday morning online, and on-air in Wednesday's Lunchtime News broadcast from 12pm during a special program dedicated to this report.
Basic checks missed
The Auditor General's office found social workers "did not adequately screen the majority of foster homes," or review those homes, when placing children – and placed 14 out of 22 children with permanent guardians "without performing basic checks such as a home study or criminal record check."
In a breathtaking paragraph, the Auditor General's staff recounted how, "In one of the files we reviewed, where screening did not occur, we found that the guardian had been charged with assaulting the child. This child was later placed in another guardianship home that had also not been screened."
Auditors challenged department staff about this lack of screening. "We were seriously concerned," they reported, "when senior departmental and authority officials told us they were unaware this was occurring." The Auditor General's office even went as far as to directly notify the territory's director of child and family services of the issue, well before the audit was complete.
In another harrowing case, a child placed in an out-of-territory treatment facility went missing for a week. There was confusion as to who should be responsible for finding them and ensuring their safe return.
The audit found that in almost 90 percent of cases, the territory's social workers failed to maintain the required regular contact with children they placed in foster care or other placements. That figure was up from just under 60 percent in 2014.
More specifically, plan-of-care agreements – which are designed to ensure parents meet conditions like maintaining sobriety or attending counselling in order to protect their children – appeared to be rarely worth the paper they were written on.
A quarter of them weren't signed on time, 15 percent weren't signed at all by at least one of the required parties, and in fully 88 percent of instances, social workers "did not maintain the minimum level of contact with children and parents," the audit declared.
Senior staff not qualified
Regular contact is considered to be important as, without it, social workers have no way of knowing whether children are receiving the care they need.
For children in temporary or permanent care, the audit said, this was a particularly damaging problem. Lack of contact meant a lack of needs assessment or planning, which contributed to children moving between foster homes 12 (twelve) times on average – and one child moving at least 20 times.
In examining changes made by the territory after the Auditor General's similarly damning 2014 report, the 2018 audit found most of the senior officials appointed to improve accountability "did not have qualifications or experience in child and family services" – and the training provided to them was not enough.
Some of those senior staff could not even access the service's own database, removing a key means of delivering the very accountability they had been appointed to offer.
Meanwhile, caseloads were high and turnover rates higher among front-line social workers, with no effective means of mitigating those issues.
In a bid to improve its services, the territory introduced a new decision-making system – named SDM – which contained six assessment tools social workers could use in managing their cases.
However, in an astonishing October 2017 report, the creators of SDM analyzed the territory's files and said they disagreed with approximately 50 percent of the decisions being made about children's safety using the tools they created. SDM's creators urged more training for NWT staff using it; the Auditor General's office found no evidence anything had happened in the year since.
Implying it had seen little to no evidence of any lasting success across the board, the Auditor General's report stated: "The Department of Health and Social Services [and related authorities] must start working on how they will achieve their common objective of providing better services and achieving better outcomes for children, youth, and families."
In a series of written responses contained within the audit's final report, the territorial government pledged again and again to do better.
In both its written responses and its own, separate report, the Department of Health and Social Services said it had improved internal auditing to better ensure compliance with all of its legal requirements.
The department said new reviews would "ensure ... meaningful contact" between children in care and social workers, as well as appropriate planning for their futures.
The department also promised to "put key standards in place" by March 31, 2019, "to provide improved direction to the system," and said it was working on better ways to design its teams and distribute caseloads.
Further, the department said staff working to place children back with family members "acted with good intentions," even in instances where their work was criticized by the audit. The department said staff would be provided with "a new standard [and] clear direction," by the end of November, on how to assign guardianship to children.
Regarding SDM, the territory said implementation of the tools was "a large and complex initiative requiring a major shift in practice," and acknowledged "a need for additional support."
The department said a new electronic case management system was helping it to do a better job of managing issues like the screening and monitoring of foster homes – something the audit suggested was routinely overlooked.
Lastly, the territorial government expressed hope that "a system-wide accreditation in partnership with Accreditation Canada," scheduled for September 2019, would help it to develop key indicators and measure the performance of child and family services.
Les Harrison, formerly Stanton Hospital's chief operating officer, was reassigned to the post of Director, Child and Family Services, in August 2018. However, the territory called the move a "temporary reassignment," implying more change and another new leader would follow. Harrison is also the assistant deputy minister for families and communities.
Follow-up audits do not often occur, but are commissioned when the findings of a first audit are significant enough to warrant one. The territorial government's last such follow-up audit, on six aspects of its operations, was in 2012.
The Auditor General's earlier, 2014 review of NWT child and family services concluded at the time there were "systemic, serious, long-standing deficiencies in services provided."
After receiving 100 separate recommendations from a range of sources, the territorial government launched an action plan to transform and improve its services in August of that year.
In 2016, the structure of health and social services in the NWT changed with the introduction of one, large health authority to replace six regional ones. The territorial government says that is still a factor – in its own report on child and family services, it wrote: "significant enhancements were still being made in 2017, and this work is expected to continue beyond 2018-2019."
The Auditor General's staff examined 37 child files and 37 foster care files in the course of the audit, from the same regions as those examined in 2014.
"From our point of view, the issue of delivery of services on the ground is of paramount importance," Wheeler, the Auditor General's representative, told reporters on Tuesday – stressing financial resources were important, but adding there had to be more cooperation between the territory's new health authority and the health department in terms of establishing where responsibilities lie.
"Children and vulnerable families in the territory are dealing with a lot," he said. "Over 80 percent of files reviewed contain references to misuse of substances; in 50 percent of files there are domestic abuse issues.
"That points to the complexity of these cases and the importance of the departments involved taking a holistic approach to these situations."
Wheeler said the NWT should "focus not only on addressing situations when they emerge, but also on prevention."
Given the apparent lack of progress since 2014, Wheeler was asked by reporters how the Auditor General's office could be sure action would be taken this time.
Wheeler said the office would monitor progress and may consider yet another follow-up.
"Should it come to pass that we don't see sufficient progress, we would certainly recommend to the Auditor General that a follow-up be undertaken," he said.