Lapses in Quebec’s youth protection system are to blame for the death of a seven-year-old girl in Granby, an internal report has found.

The final report, made public Wednesday afternoon by the regional health board in the Eastern Townships, did not place the blame on any one service but rather the system as a whole, which the report said “failed in many ways and at different times.”

“The social safety net has not been effective enough to prevent the death of this child,” the report reads.

The report includes 14 recommendations to improve the safety and development of children and ensure there are better systems in place to support service workers and follow up on cases. 

The new regional director of youth protection services, Dr. Stephane Tremblay, said the system failed several times throughout the girl's life because it is flawed. 

"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."

Officials told a news conference Wednesday that the social safety net wasn't effective enough to prevent the death of the girl, whose identity is protected by court order.

She 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.

Various case workers failed to use best practices to communicate crucial information about her situation and left her in danger in the lead-up to her death, said Tremblay. 

"The transfer of information may not always have been exemplarily managed, either within our services or with our partners," he said.

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. "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'."

Tremblay said some specific people are being targeted by police, as part of a separate investigation. 

Some of the recommendations include calls for better communication between youth protection services, schools, health care workers and all those involved in these cases.

  • ensure case workers visit the child's home as often as possible
  • propose changes to the Youth Protection Act that dates back to the 1970s to include stepparents
  • ensure case workers understand their role and responsibilities
  • make efforts to recruit and retain personnel: much has been said about what a difficult job being a case worker is and the difficulty retaining qualified personnel.

Youth protection for the Eastern Townships said it's in the process of reviewing all 1,900 of its cases. About 40 per cent have been reviewed so far in order to ensure nothing's been missed and that those children are not in danger. 

They are seeking to complete that revision by the end of August. 

In the meantime, the Surete du Quebec, the Quebec Human Rights Commission, the coroner's office are all looking into what led to the girl's death.

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."

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.

- With files from Sidhartha Banerjee of The Canadian Press