Brandon Schafer-Kovacs died in care. An inquest calls for change. Will the province listen?

The inquest into the 2022 death of Brandon Schafer-Kovacs wrapped up Wednesday, with the jury charged with making recommendations to avoid similar deaths.

Brandon Schafer-Kovacs died sick and unseen in 2022. Now, his family and a coroner’s jury demand accountability from Saskatchewan’s child welfare system.

“I just wanted to say that we miss him terribly and loved him dearly and that his life mattered,” Schafer-Kovacs’ grandmother Cathie Pocha said, speaking on behalf of the family.

After three days of testimony from family, staff involved in his care and Ministry of Social Services administrators responsible for his well-being, a jury of six civilians had four recommendations, and Coroner Blaine Beaven offered one of his own.

Throughout the inquest, the jury heard about unclear policies, a complicated hierarchy of decision making and communication breakdowns at Eagle’s Nest Youth Ranch.

After returning from deliberations Wednesday, the jury called for changes at Eagles Nest Youth Ranch, which operated the Saskatoon group home on 1st Avenue Schafer-Kovacs lived at prior to his death:

1. All mandatory training must be signed by the employee and the manager’s supervisor with a copy provided to the Ministry of Social Services
2. That staff receive sensitivity training to improve their insight into the needs of the children in their care, and the reasons underlying their behaviours
3. Establish clear separation in reporting, to keep client-focused activity logs distinct from house operations logs
4. All group home staff must document all interactions and communications with anyone outside the home.

Coroner Blaine Beaven recommended the Ministry of Social Services review the recommendations of the jury and consider including them in the Residential Services Manual (RSM), a policy document detailing a minimum standard of care for group homes across Saskatchewan.

Whether these recommendations are put into action or not is up to the groups charged with the safekeeping of the province’s most vulnerable kids.

“The family hopes for the quick and thorough implementation of any recommendations to help safeguard children in the ministry’s care,” said Christine Libner, the Schafer family’s legal counsel.

The third day of the inquest heard testimony from leadership within the Ministry of Services who were not directly involved in Schafer-Kovacs’ care but were overseeing programming or were responsible for group homes.

The jury heard of several gaps currently present in group home policies and oversight pertaining to contracted groups like Eagle’s Nest, which has held a contract to take care of children since 2007.

Much of Wednesday’s testimony was about the RSM and the length of time it has taken to implement urgent changes to the rules for caregivers.

Contracted companies can have their own policies, but they must align with the RSM.

The jury learned a series of changes are being made to the RSM in the wake of Schafer-Kovacs’ death on Nov. 28, 2022, from severe septic shock after contracting a deadly combination of influenza A and streptococcal pneumonia.

One issue: they’re only in the draft phase and have not been officially amended, nearly three years after the teen’s death.

Erin Gagne, the director of community response services with the Ministry of Social Services, said a series of amendments were drafted and sent to the Saskatchewan Advocate for Children and Youth, who has yet to send the document back to be finalized.

Some of the changes include having over-the-counter medication like Tylenol in supply, as well as in vehicles. Thermometers also need to be readily available.

Jurors previously heard Schafer-Kovacs didn’t have his temperature checked, despite staying in bed sick for more than four days with flu-like symptoms. Staff members testified a thermometer on site didn’t have batteries or wasn’t functioning.

Group home staff must notify parents if a child becomes ill or needs medical treatment and provide clear documentation. Previously, group home staff were only required to report illness to the case worker, the main point of contact with family.

Other changes include training and knowledge for common illnesses like respiratory illnesses, influenza, gastroenteritis and the administration of common medications like Tylenol.

Once the RSM is finalized, it will be shared among the ministry and then passed down to all contracted group homes, but how they ensure a group home is compliant wasn’t clear.

Gagne said a death in a provincial group home doesn’t trigger an automatic review of policy.

Dave Smith, another administrator in the ministry, said Eagle’s Nest has made a series of changes following a quality assurance review that would meet the updated requirements.

Gagne said the ministry does not go through a company’s policies line by line, and there is no mechanism in place to compare Eagle’s Nest policies with the new provincial requirements, since they aren’t official yet.

Jurors also learned new training provisions are only required for new group homes being added to the provincial portfolio, or new employees joining a contractor, not for existing contractors like Eagle’s Nest.

Eagle’s Nest remains a contracted group home of the province. Smith said its internal changes have been satisfactory, despite the avowed lack of direct oversight from the ministry.