When Toronto police arrived at an apartment in October 2018, officers were horrified by what they discovered.
The overwhelming stench of cigarette smoke and cat feces filled the air. The floors and walls were filthy. Soiled pull-up diapers lay scattered around the residence.
Cockroaches — both live and dead — covered the floor.
And wrapped in a dirty blanket on a bare, urine-streaked futon was a 10-year-old boy in a “catatonic” state, according to a newly released report from Ontario’s Ombudsman.
After being rushed to hospital, the young boy was found to be malnourished, almost anaemic, and 15 pounds underweight for his age and height. One of his kidneys was enlarged and appeared to be infected.
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A doctor credited the police intervention with saving the child’s life, the report found.
It also noted that the Children’s Aid Society of Toronto refused to take him into protective care, despite his condition and the state of the home.
When police learned CAS Toronto had no intention of apprehending the child, they did so themselves and took him to a foster home. He remains in foster care today.
The heartbreaking story of Brandon — a pseudonym used to protect the boy’s privacy — was laid out in a scathing report from Ontario Ombudsman Paul Dubé that revealed stunning and repeated failures by CAS Toronto.
“The standards that are in place to keep children safe when they’re receiving services … were departed from consistently,” Dubé told Global News in an interview.
“What we’ve done is shine a light on the devastating impacts of not following those rules.”
This is the first report to be released by the Ombudsman’s child and youth unit since it assumed responsibility for investigating concerns related to the child welfare system in 2019.
The Ombudsman, who also investigates complaints in other sectors like jails and schools, now also oversees complaints from kids in the care of the province.
Child welfare experts told Global News it was concerning that the Ombudsman’s report took more than four years to produce and, in the meantime, could have led to improvements in care.
“How many Brandon’s have there been in the time it took to come up with recommendations from an investigation that [started] four years ago?” said Kiaras Gharabaghi, dean of Toronto Metropolitan University’s faculty of community services. “How many more will there be given that the recommendations basically say nothing beyond ‘Everybody, please do your job?’”
The report covers a period from 2015-2018, when Brandon was between the ages of seven and 10. It showed years of delayed investigations, safety assessments that were conducted improperly, and warnings from professionals like police, teachers and principals that were not given “careful consideration.”
The report also found that multiple, successive CAS workers failed to meet with Brandon at regular intervals or privately with him to discuss his care.
“CAS managers gave little credence to the eyewitness accounts of the horrific state of Brandon’s living environment on October 22, 2018,” the Ombudsman alleges in his report.
“Rather than proper diligence, [CAS Toronto’s] actions were characterized by delays and deficiencies.”
Dubé agreed the investigation took “an awfully long time,” explaining that the complexities of amalgamating two offices and the pandemic caused unexpected delays.
In response to emailed questions from Global News, Toronto CAS said they “fully support” all of the Ombudsman’s recommendations and are working on their implementation. It has begun new file reviews and staff training.
“We are continuously focused on learning, development and garnering critical feedback,” said Elissa Schmidt, director of communications.
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The CAS wouldn’t comment on the specifics of Brandon’s case, nor on whether any of its employers were reprimanded for failing to meet provincial standards, citing privacy concerns.
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Throughout the 90-page report, Dubé reveals the tragic details of Brandon’s life from the time he was first taken into child protection services at just four months old until he was apprehended by police at age 10.
His mother, identified as “Cindy,” spent time in the care of the child welfare system herself after experiencing neglect and abuse, according to the report. She lives with cognitive and developmental issues.
Over the last two decades, children’s aid societies across Ontario have shifted away from using foster and group homes, focusing instead on placing children with relatives whenever possible.
Brandon spent most of his life in the care of his grandmother and his great-uncle, who has a history of alcohol abuse.
From 2014 to 2018, CAS Toronto conducted five different investigations after receiving multiple reports about Brandon’s hygiene, well-being and living conditions.
Provincial standards state these investigations are supposed to be completed within 45 days, but the Ombudsman found extensive delays in many of the investigations. In one case, an investigation had continued for 150 days.
Over those years, teachers, his principal and doctors raised concerns about inappropriate and violent behaviour, as well as his hygiene and school attendance record. Doctors highlighted his history of painful urinary tract infections that his caregiver failed to address, according to the report.
In one incident in 2017, a vice-principal at Brandon’s school reported to the CAS that the boy, then nine years old, had come into the office and began rocking on a bench and holding his hands towards his genitals.
“If you want to help me, get me a knife so I can kill myself, just leave me alone,” Brandon said, according to an interview the vice-principal gave to the Ombudsman’s office.
The police were called and would later report to the CAS that Brandon had told a Mobile Crisis Intervention Team “he didn’t want to die, but was in pain due to an infection.”
Every time, the CAS closed its investigation after speaking with the family.
“The CAS was distracted by the assurances of Brandon’s family,” the Ombudsman said in his report. “It lost sight of its responsibility to act in his best interests, leaving him to suffer in silence in a situation of chronic neglect.”
The Ombudsman issued 18 recommendations to CAS Toronto to prevent situations like this from happening again. Among those recommendations were that investigations and safety assessments be completed in a timely manner, family members be interviewed in private, and that workers actually meet with the children in their care.
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Brandon’s story, the Ombudsman said, “is not one of deliberate caregiver neglect, but of failure of his family to meet his needs, given their own significant challenges.”
“The sequence of gaps and failures that occurred — many of which appear inexplicable — should not be viewed as a singular or ‘one-off’ situation,” the Ombudsman said in his report.
“[Toronto CAS] should use Brandon’s story as a learning exercise for its staff, and a reminder that their work must be centred on the best interests of the child.”
The Ministry of Children, Community and Social Services said in a statement to Global News that “children’s aid societies are required to comply with their responsibilities under the CYFSA” and that it takes the findings of the Ombudsman’s report “very seriously” and is “currently reviewing its recommendations.”
An ongoing, year-long investigation by Global News into the quality of care of Ontario’s child welfare system has uncovered little accountability and government oversight. It has also revealed concerns about Premier Doug Ford’s decision to shutter the Child Advocate’s office.
Some experts have said the Ombudsman doesn’t have the same ability to expose problems inside the child welfare system like the Child Advocate once did.
The report into how CAS Toronto handled Brandon’s case was started by the Child Advocate prior to its closure and was prompted by a complaint from police.
“The elimination of [the Child Advocate] by the government was perhaps the single most catastrophic thing to happen to vulnerable children in Ontario,” Gharabaghi said.
“Children involved in child welfare and youth justice are worse off and will be worse off for years to come.”
Ontario’s former advocate for children and youth, Irwin Elman, said the report is “a good piece of work for what it is: a dive into the administrative fairness of the child protection system,” but he questioned why Brandon’s voice wasn’t featured more prominently.
“The report is not about the production of a chair or some other object. It is a report about a child — a child who suffered as we gazed right past him. His voice, his humanity is missing.”
When asked, Ombudsman Dubé said his team had been “in touch” with Brandon, but could not confirm whether the 10-year-old had been interviewed for the report.
Toronto Children’s Aid is supposed to report back to the Ombudsman’s office within six months with an update on its implementation of the recommendations.
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