INQUEST REPORT TAKES AIM AT CHILD WELFARE, JUSTICE SYSTEM
Girl's death -- society's failure
Winnipeg Free Press
A Manitoba Judge-haunted by images of 23-month-old Nadine Beaulieu's battered, emaciated body-has issued a stinging report into society's failure to protect the little girl from a gruesome death.
The 200-page inquest report raises alarming questions about Child and Family Services and the failure of the justice system to bring Nadine's killer to justice.
And in a remarkable move, provincial court Judge Roger Gregoire has suggested CFS consider naming one of its facilities in honour of Nadine "to serve as a reminder to all those who work in child welfare to be ever vigilant in order to prevent this type of tragedy."
Nadine died February 21, 1996 in Winnipegosis, about 270 kilometers north of Winnipeg, after being placed in foster care by West Region CFS in the nearby Pine Cree Reserve, population 800.
The foster parents had no training, weren't properly screened for criminal records and were improperly supervised by an overworked CFS employee, Gregoire has found.
Residents on the reserve were aware of problems and concerns with Nadine's health and her foster parents-including their criminal history-but took little action to report it to authorities, he said.
"On many occasions...as I viewed the very disturbing photos of the poor little emaciated and battered body that lay upon the autopsy table, I questioned whether Nadine's life was sacrificed on the alter of social expediency in society's rush to attempt to correct the social wrongs of past generations," wrote Gregoire.
An autopsy revealed Nadine's cause of death as "the application of force by an adult person to her abdomen," which caused a rupture and internal poisoning.
"It appears she was struck with tremendous force. Her death was by no means sudden. It would have taken many hours for the digestive juices and partially digested food to seep out into her abdomen, causing the infection which killed her," said Gregoire.
There were numerous other signs of abuse on Nadine, including at least 75 recent bruises on her face, scalp, chest walls, lower abdomen, back, buttocks and extremities, scattered roundish scars and small abrasions; inter-abdominal bruising on her stomach wall and connective tissue on the pancreas; and dehydration, including sunken eyes and dry skin.
She was also severely undernourished, with the ribs clearly evident and her buttocks emaciated. And there was evidence of a broken right pelvis and three broken ribs, both of which were healing at the time of her death.
Despite the abuse suffered by Nadine, no one has ever been held responsible for her death.
Nadine's foster parents, Clifford and Laura Richar, were charged with manslaughter and failing to provide necessities of life, but the case was thrown out of court because of RCMP mistakes in obtaining a statement from the accused.
In a statement to police, Clifford Richard, 33, had told investigators he hit Nadine in the stomach with a backhanded swing of his arm because he was angry she kept trying to get some fried chicken.
The Richards both testified at the inquest and maintained they did nothing wrong.
But the judge said Clifford Richard's testimony lacked credibility and he often changed his story.
"It was difficult to believe him on much of what he says," said Gregoire.
"I cannot say with any degree of certainty that he is the one who inflicted the blows that killed Nadine; however, I am left with the distinct impression that I was not getting the entire truth from Mr. Richard and he knows more than he is telling the court," said Gregoire.
Richard testified that Nadine was a "handful." As a possible explanation for Nadine's injuries, he claimed Nadine was running up and down stairs and may have injured herself.
Hours later, she began vomiting. Richard said the illness continued through the night, and was worse by morning. He told his wife to give her a bath while he called a cab.
Richard claims he gave Nadine CPR in the cab, and that she was "rubbery" but breathing. He also claimed Nadine hit her head on the cab as he took her inside, but denied hitting or kicking her in the stomach.
Richard also claims Nadine fell out of the top bunk of her bed and struck the floor two weeks before her death. He never took her to a doctor, even through she was walking in an unusual way afterward. Nadine also fell twice the day before her death, and was jumped on by some other children while play fighting, he said.
The province's chief medical examiner called an inquest after criminal charges were stayed against her foster parents. The inquest began September 24, 2001, and ended March 5, 2003. In total, there were 43 days of evidence, during which 46 witnesses testified.
Gregoire said the inquest was "a quest for answers, but unfortunately, many questions remained unanswered."
"Unfortunately...I am unable to come to any definite conclusion as to who was the individual who inflicted the blows which led to Nadine's death. I was left with an uncomfortable that there is an attempt to cover up exactly what happened by the person or persons involved and by those who have knowledge of what occurred," said Gregoire.
"Nadine deserved to have her short life and death carefully scrutinized in order to determine as far as possible what happened, why it happened and what could have been done to prevent her death."
Gregoire has made 71 recommendations for change, many of them aimed directly at CFS (Child and Family Services)
"For the loss of life there can be no scapegoats. All of society has to accept and share some of the responsibility for her untimely death and collectively move forward toward a time when children can truly be safe in our communities."
Nadine's family history is filled with tragedy. Her mother was born in 1974 into an abusive family and was quickly seized by CFS. She was 20 years old when she had Nadine, her third child. Four more quickly followed.
The woman is an alcoholic and has lost all seven children to CFS.
Nadine's birth father has a lengthy history of child abuse, both as a victim and offender. He has a lengthy criminal record, including a bugger conviction against a child.
Both parents-who can't be named under a court order-led turbulent lives filled with violence, abuse and poverty. They moved throughout Manitoba, and the children were often left with relatives while they partied.
Nadine and her two siblings at the time were eventually apprehended and placed with the Richards, who had two children of their own. The couple was paid $37.00 a day per child.
Clifford and Laura Richard had recent criminal records for assault and drunk driving, but that information was never disclosed to CFS. When it was eventually discovered during criminal record checks, the foster children were already in their care and not removed.
"It appears there was a certain willingness on the part of the agency to bend the rules somewhat in order to obtain foster homes," said Gregoire.
"This is unfortunate as had the agency followed its own policies in regards to foster home licensing, the Richard home would not have been approved."
Agency workers also didn't realize the toddler likely suffered from fetal alcohol syndrome, despite numerous "red flags" related to her behaviour.
Glennis Mousseau, the CFS worker responsible for Nadine, has been on an extended stress leave since 2001. She testified her caseload involved 50 children and 30 other family files. She trained in-house by CFS, but had no formal or university training.
Wayne Govereau, the children's advocate in Manitoba at the time of Nadine's death, was critical of CFS for failing to properly document their visits to the girl's home and provide information about her care.
Only Mousseau and a second CFS worker ever visited the home. They described a girl who had "high needs," was developmentally delayed and would often gorge on food, the sign of a deprived child.
Here are the key recommendations from the inquest:
All child-care workers, health-care workers, teachers and day-care workers should be given mandatory education and training in fetal alcohol syndrome (FAS) and its effects to assist them in recognizing children who are suffering.
Parents and foster parents of FAS children should receive ongoing training and support.
Where a child-caring agency is aware that a mother has a history of alcohol use during pregnancy, a mandatory FAS assessment should be done to ensure early diagnosis, intervention and support.
If one child is found to be suffering FAS, other biological children of the same mother should be assessed.
The provincial government should consider legislation to protect fetuses from the effects of substance abuse.
Specifically trained home-care aides should regularly visit newly licensed foster parents caring for preschool children for the purposes of interacting with these children.
CFS workers should make it clear to all foster parents they have the right to request a child be removed from their home.
West region CFS (this is the agency Nadine was under) should drastically upgrade their training of all front line and supervisory staff.
West region CFS should reinforce with their social workers the importance of maintaining detailed recording and notes.
West region CFS will ensure reasonable caseload limits are reduced from the numbers at the time of Nadine's death.
The College of Physicians and Surgeons of Manitoba should provide further notice to all of its members about the prevalence of FAS on society and make them aware of an FAS clinic that can assess children.
The province should engage in a promotional campaign in aboriginal communities to make all members aware of their responsibility to report suspected child abuse.