The system as a whole — not one person or service — is to blame for lapses in the case of a slain seven-year-old Quebec girl who'd been followed by youth protection, according to an internal probe by the regional health authority released Wednesday.
The investigation found cracks in the system failed her at different times and in different ways and that a "succession of events that should not have occurred" led to a high-risk situation before her death.
The findings of the regional health board in the Eastern Townships region also came with 14 recommendations to prevent a recurrence, focusing on better management, rigorous monitoring and follow-up and more staff and support.
The Quebec government has ordered several other investigations stemming from the case of the young girl from Granby, Que., who'd been followed by youth protection services from birth and whose death sparked outrage across the province and raised questions about the effectiveness of the system to assist at-risk children.
"The analysis of the event revealed that throughout the life of this child, the health and social services network offered her a wide range of services and her family," the health board said in a statement. "All stakeholders and managers involved with them have demonstrated their commitment to this family."
Dr. Stephane Tremblay, who oversees the agency in the region, said Wednesday that 19 experts examined a wealth of documents and concluded the social safety net wasn't effective enough to prevent the death of the girl, whose identity is protected by court order.
Tremblay said the errors in question were primarily in terms of communicating information between different parties over the past several years.
"The transfer of information may not always have been exemplarily managed, either within our services or with our partners," he said.
But he said there was no ill intent on the part of workers, who are overwhelmed and understaffed.
"It's not bad faith on the part of staff, it's not incompetence of our interveners, there are limits to what they can do on any given day," Tremblay said in Sherbrooke, Que. "When we meet with staff, when we see them, what people tell us is 'We're not able to do what we should in a day'."
The girl was found in critical condition in her family home in Granby, about 80 kilometres east of Montreal, on April 29 and died a day later in hospital.
The victim's stepmother faces one count of second-degree murder, unlawful confinement and aggravated assault.
The young girl's father faces four charges: criminal negligence causing death, unlawful confinement, failing to provide the necessities of life, and child abandonment.
In response, the government launched a wide-ranging independent commission into youth protection in the province.
It will have an 18-month mandate and issue a final report with recommendations by Nov. 30, 2020, at the latest.
Several other investigations have been ordered into the handling of the girl's case, including a coroner's inquest and an investigation by the Quebec Human Rights and Youth Rights Commission.
Questioned about doling out blame, the province's junior health minister said they would wait for the results of other investigations.
"We'll wait for the other investigations before blaming anyone, but we will apply the recommendations," Dr. Lionel Carmant, the minister who oversees youth protection, said in Quebec City. "We must wait for the results of all the investigations before taking any decisions."