JURY RECOMMENDATIONS CONCERNING THE DEATH OF JORDAN DESMOND HEIKAMP

The following recommendations are not presented in any particular order of priority.

  1. We the jury recommend, that it should be made clear to all Child Protection Workers and their Child Protection Supervisors that their client is the child in need of protection not the parent or the family.

    Rationale:

    The evidence shows that the focus on this case was primarily on the mother and not on the child.

  2. We the jury recommend, that the Ontario Association of Children's Aid Societies provide assistance in an internal Children's Aid Societies review of serious incidents such as death of a child. Internal reviews by colleagues are of assistance but require the input of a neutral and critical outside reviewer. In the event of a Criminal Investigation, the Children's Aid Society should complete a full investigation unless advised in writing by the police to cease such an investigation. The general overall recommendations (not disclosing the client's or employee's names or personal information) resulting from the review should be shared with all staff as a learning tool. All child protection workers in Ontario should receive a concise overview of the facts surrounding Jordan Heikamp's death.

    Rationale:

    Evidence indicated that the review was stopped before it was completed due to the police investigation.

  3. We the jury recommend, that the Ministry of Community and Social Services develop a public awareness and education program about the harmful effects of child neglect and abuse and the importance of early detection and intervention.

  4. We the jury recommend, that the Ministry of Community and Social Services provide funding for the human resources required to undertake ongoing education to the professional community on Duty to Report.

    Rationale:

    It appears that the Duty to Report obligations under the Child and Family Services Act may not be widely known. In addition, there is some confusion among various agencies and professionals as to what the duty entails and what should be reported.

  5. We the jury recommend, that the Ministry of Community and Social Services provide funding to the Children's Aid Societies for the provision of Pregnancy and After-care Services to young mothers without support, including the capacity for outreach and early intervention at the prenatal stage.

    Rationale:

    Access to prenatal education and medical resources needs to be made available to this unique population. Children's Aid Societies can greatly assist young mothers through early intervention and outreach programs that contribute significantly to better working relationship between Children's Aid Workers and young mothers.

  6. We the jury recommend, that meetings with clients, when possible, should take place in their own surroundings (home, shelters, etc.).

    Rationale:

    The worker is then able to observe how the client is coping in his/her environment, and possibly see care workers and speak to them as well as the client.

  7. We the jury recommend, that all child protection workers should be cautioned that some young people who reside or have resided in shelters have become adept at lying and manipulating. The caseworker should confirm the accuracy of information received from the caregiver whose parenting skills are being investigated and assessed, even if the caregiver presents well and there is no apparent reason to doubt him or her.

    Rationale:

    All observations about baby Jordan were done and discussed with his mother. Nothing was checked out or confirmed.

  8. We the jury recommend, that the Ministry of Community and Social Services and the Ministry of Health ensure that a full and comprehensive education and training program in the Street and Shelter Culture be established that addresses the needs of vulnerable children and youth and that it be for all Children's Aid Societies, Hospital, Shelter and Public Health Employees. Funding such a program provided for by both Ministries.

    Rationale:

    Evidence showed there was a lack of knowledge in this area.

  9. We the jury recommend, that all Children's Aid Societies amend their policies to include a weekly face to face visit with the child where the child is a newborn infant under four (4) months of age. The twenty-one (21) days allowed for risk assessments should be shortened to seven (7) days.

    Rationale:

    Evidence showed that even after the June 12th. observation, another face to face visit with baby Jordan might have confirmed in the social worker's mind that the baby had not gained weight.

  10. We the jury recommend, that all Children's Aid Societies reflect a turn around time of a minimum of fifteen (15) days as opposed to thirty (30) days for all children under six (6) years of age.

    Rationale:

    Evidence showed that this age group is the most vulnerable and warrants a shorter turn around in time.

  11. We the jury recommend, that all Children's Aid Societies adopt a critical role as well as a supportive role for their social workers.

    Rationale:

    Evidence showed that the social worker played a supportive role or advocacy role for the mother of the child and a more critical role was required.

  12. We the jury recommend, that the Ministry of Community and Social Services accept and implement the eleven (11) recommendations set out in the "Final Report, Ontario Risk Assessment Model, Phase I: Implementation and Training" by Nice Trocme et al (1999).

  13. We the jury recommend, that the Ministry of Community and Social Services and the Ministry of Health to provide funding to ensure that each of the Children's Aid Societies have a minimum of one Pregnancy After-Care (PAC) Worker to provide pregnancy and after-care services to first time mothers, including the capacity for outreach and early intervention at the pre-natal stage. Both Ministries should commit to the prompt implementation of the appropriate funding model so that women's and family shelters are provided with sufficient resources to adequately ensure that the pre-natal and post-natal care of children and to provide aid in the growth and development of the children at the shelters.

  14. We the jury recommend, that Supervisors of the Children's Aid Societies should conduct regular reviews of the intake worker's files and case notes to ensure that all policies and procedures are being compiled with. The supervisors should document as much as possible their involvement in a file.

    Rationale:

    It was difficult to determine when the initial assessment had been completed by the intake worker and then reviewed by the supervisor.

  15. We the jury recommend, that the Ministry of Community and Social Services in conjunction with Ontario Hostel Association (OHA), Ontario Association of Interval and Transitional Housing (OAITH), the Hostel Services of Toronto, the Hostel Training Center and the Canadian Union of Public Employees (CUPE) develop and establish policies and standards for the education of shelter workers in the province that will include but not be limited to:
    • Dedicated funding for educational training and back fill costs
    • Designated and dedicated number of days per year for each employee to devote to training
    • Pre-workload training period for new employees
    • Components dealing with documentation
    • Components dealing with interview skills and verification of information
    • Components dealing with Models of Care and Plans of Action
    • Components dealing with Failure to Thrive
    • Components dealing with the Child and Family Services Act

    Rationale:

    To recognize the on-going needs for shelter workers to receive training in order to carry out their duties and responsibilities in a manner that will meet the needs of the client.

  16. We the jury recommend, that the Ministry of Health increase funding to the Public Health Departments and the "Healthy Babies, Healthy Children" Programs to provide mandatory home visits to mothers who receive a "high risk" score on the "Healthy Babies, Healthy Children" screening tools and to provide outreach on a regular basis to Youth Shelters and Women's Shelters to ensure the provision of:
    • Health education
    • Routine health assessments, and feeding and care of baby
    • Effective linkages and referral with other medical professionals.
  17. We the jury recommend, that the Ministry of Community and Social Services and the City of Toronto should look into the feasibility of opening another shelter like Robertson House with similar services and programs. We suggest this shelter be called "Jordan's House"

    Rationale:

    It has been proven that there is a lack of appropriate facilities available for pregnant street and shelter youth.

  18. We the jury recommend, that the City of Toronto Hostel Services develop a protocol to be incorporated into Hostel Standards for shelters that require immediate notification to the Public Health Department of the admission of a young pregnant woman without support to a shelter.
  19. We the jury recommend, that the City of Toronto Hostel Services work with each youth and family shelter to ensure that they include consent forms to be signed by the client, in particular, youth at intake. This enables the sharing of information between shelters and the tracking of young pregnant women in the shelter system.
  20. We the jury recommend, that if arrangements have been made for a pregnant teenager to check into a maternity home on a specific date, a care worker should accompany her.

    Rationale:

    Evidence indicated that a young pregnant woman was put into a taxi, but never showed up at the maternity home.

  21. We the jury recommend, that Shelter staff should not wait for clients to ask for help, because you cannot make them ask (they may not see the need). Help should be offered and it should be up to the staff to evaluate whether help is needed. Assess the situation on a regular basis.
  22. We the jury recommend, that information on birth control, pregnancy, counseling and other health related topics should be easy to access at youth serving agencies and appropriate for this population, Use of other sites where street youth may gather should be used (in malls, bus stations, etc.) for outreach and information dissemination.
  23. We the jury recommend, that many graduates from the Assaulted Women's and Children's Counselor/Advocate Program become front line workers in homeless shelters within the Toronto area. Many of their students' field placements are in these shelters. It is critical that this program provides more training and education in the area of child development and parenting techniques.
  24. We the jury recommend, that the Public Health's services for at-risk mothers be widely advertised to doctors, shelter workers and street workers who have a support relationship with street youth, The Public Health intake telephone number (416-338-7600) should be on display in locations that are frequented by homeless youth.
  25. We the jury recommend, that ongoing education and counseling including parenting, life-skills and nutrition should be available in family shelters and at drop-ins, delivered by public health nurses and others associated with these facilities.
  26. We the jury recommend, that the Child and Family Services Act should be amended to include a new provision in Part III (Child Protection) that authorizes child protection agencies to have access to information and records related to a person, without the need for that person's consent or a Court order, in the following circumstances:
    • If the information is believed to be necessary to investigate allegations that a child is or may be in need of protection;
    • For the purpose of a proceeding or possible proceeding under Part III (Child Protection) of the Child and family Services Act;
    • If the information is necessary for monitoring court orders.

    Rationale:

    A free flow of information is critical to the care of infants like baby Jordan.

  27. We the jury recommend, that all persons working in shelters where newborns sometimes stay should receive a concise overview of the facts surrounding the death of Jordan Heikamp. This statement should emphasize the importance of:
    • Exercising caution in relying on the word of a child's caregiver.
    • Ensuring that, when a child protection worker is involved, the shelter workers and the child protection worker have a clear, detailed understanding of exactly what each will be doing and not doing in relation to a vulnerable child who is living in a shelter. A written statement of this mutual understanding should normally be prepared.

    The Ministry of Community and Social Services license shelters that provide staffed residential services to women and children. The licensing requirements will address standards of service, appropriate staffing levels and other issues, which contribute to the safety of the residents, including:

    • Pregnant youth residing in shelters will be expected to participate in appropriate pre-natal programs and care;
    • Youth shelters and shelters for women and children will be expected to develop a service arrangement with a consistent medical practitioner on their local community;
    • Shelters providing care to children and their parents must consider the child as an individual client, including a plan for services required to meet the child's needs;
    • Regular observation and assessment should be made regarding both adult and child residents of shelters;
    • All shelters that provide residential services to mothers with infants require verification of routine medical visits for the infant up to twelve (12) months of age.

    Rationale:

    In order to effectively service this population it is imperative that a policy be developed that will clarify what services a shelter does and does not offer.

  28. We the jury recommend, that in addition to adequate nursing staff on hospital obstetrical units and nurseries, hospitals should be encouraged to have a designated lactation consultant on staff.
  29. We the jury recommend, that funding should be provided to clinics, hospitals and public health departments for the hiring of lactation consultants, nurses and/or midwives. Funding should be sufficiently allocated to ensure that twenty-four (24) hour breastfeeding clinics are available.

    Rationale:

    Designated lactation consultants make it easier for hospitals to ensure that all mothers learn how to breastfeed especially in situations where the mother has a short stay at the hospital or she is discharged before the baby.

  30. We the jury recommend, that mothers whose "Healthy Baby, Healthy Children" screening tool score exceeds, for example twenty-five (25), should receive a home visit from a Public Health Nurse. This should occur even if a Children's Aid Society has been notified about the child's situation.
  31. We the jury recommend, that the Public Health Nurse must visit at least once a week. Equipment must be available, such as a weigh scale, etc. The Public Health Nurse should check infants less than four (4) months old (physical check-ups, weighing, etc.).

    Rationale:

    Relying on others proved to be critical in baby Jordan's life.

  32. We the jury recommend, that a standardized and mandatory discharge sheet or "passport" be developed by the Ministry of Health and used by all hospitals. This form will be available to all hospitals within a defined period of time. It should include at the very least:
    • Date of Birth, weight at birth
    • Complications, abnormalities or illnesses treated
    • Immunizations given
    • Screenings done (for example: Thyroid and PKU)
    • Feeding at the time of discharge; type of milk, frequency
    • amounts per feed,
    • Weight at discharge
    • Date and time of follow-up, within seven (7) days, and name of follow-up health professional
    • Special tests (for example: Hearing tests) or special appointments.

    A written summary should be provided to all mothers at the time of hospital discharge. This may take the form of an "infant passport" or a pre-structured summary in the form of Exhibit #102

    Rationale:

    In 1997, some hospitals did not have such a form for hospital staff to give to new mothers. It is agreed that the form developed by Hamilton-Wentworth in 1999 would be a useful tool to model a uniform discharge summary (Exhibit #102). Some amendments should be made to the form (for example: The method of feeding should be included).

  33. We the jury recommend, that if the mother is discharged before the baby, a duplicate of all information in the mother's file should be transferred to the baby's file.
  34. We the jury recommend, that when a newborn is discharged from hospital and a child protection worker has undertaken to investigate and assess the parenting capacity of the child's primary caregiver, the child protection worker should confirm with hospital staff that an appointment has been made for the child to be seen by a health care provider, and the child protection worker should subsequently confirm with the health care provider that the appointment was kept.

    Rationale:

    In this case, there was no follow-up care by a physician. The hospital and the Catholic Children's Aid Society had a different understanding as to who the follow-up physician was. No verification was made to ensure that the mother actually took baby Jordan to the doctor. Mandatory verification is not necessary for all mothers, but only mothers who are identified as high risk.

  35. We the jury recommend, that hospitals and child protection agencies should review policies to ensure clear communication between hospital staff and child protection workers. Input from the hospital staff regarding concerns should be fully communicated and assessed by the child protection agency. Face to face meetings by the assigned child protection worker and all relevant hospital staff should be encouraged and arranged by the child protection worker when hospital staff raises concerns. Information flow should be both ways. In addition to obtaining all relevant information from hospital staff, child protection agencies should inform staff of the relevant issues (for example) transportation issues and eating disorders) which may be important for the baby's care while in the hospital.

    Rationale:

    There is evidence that the social worker did not hold meetings with the nurses and did not review hospital records.

  36. We the jury recommend, that it be suggested that each Hospital Board delegate an individual who will be responsible to look at the recommendations submitted by this jury and the feasibility of their implementation. This person could also be responsible for on-going education, monitoring of pre and post-natal discharge policies, and maintaining contact with relevant community groups in their geographic area.
  37. We the jury recommend, that when hospital staff make a referral to a Children's Aid Society regarding a child, the hospital will automatically involve the Hospital Social Worker. The social worker will remain involved with the nursing staff to resolve problems as they arise in the hospital, along with:
    • Act as liaison between hospital, family and the Children's Aid Society, to share and provide information as required and/or permitted by law;
    • Assist in any required follow-up intervention when appropriate;
    • Will remain involved with the family care while the baby and/or mother remain in the hospital, even when a referral has been made to a Child Welfare Agency
    • In situations where there is no Hospital Social Worker one person should be
    • assigned to discharge the facilitative role.

    Rationale:

    Where a child, particularly a newborn infant, is transferred from the medical system to the child welfare system, there is need to ensure that the move occurs with optimal communication.

  38. We the jury recommend, that manufacturers of all baby formula should put on the labels of their product a warning of the danger of diluting the formula without the specific recommendation of a physician. This warning to be placed in a conspicuous place on the label.

    Rationale:

    The mother of baby Jordan was diluting the formula to such a degree that any nourishment supplied was insufficient for him to survive on.

  39. We the jury recommend, that any mother discharged from hospital intending to breastfeed, but where the feeding has not been established, are seen within 24-48 hours by a lactation consultant. Also that signs of infant hydration and successful breastfeeding be taught in the pre and post-natal periods, along with the proper hygiene care of breasts. The appointment for the lactation consultant be included in the standardized discharge summary, and where appropriate, the same verification system as for doctors visits be in place: Information regarding breast or bottle feeding difficulties, and how to recognize when feeding is going well and signs of distress;
    • Twenty-four (24) hour availability of hospital nursery nurses;
    • Twenty-four (24) hour telephone number for breastfeeding information and assistance,

    Rationale:

    Proper care of a newborn infant can only be provided if those responsible for that care are aware of the infant's needs and are capable of meeting those needs.

  40. We the jury recommend, that the "Healthy Babies, Healthy Children" Postpartum screening tool should be completed and forwarded to Public Health for all children regardless of consent. Sufficient funding should be allocated to the "Healthy Babies, Healthy Children" program to allow the implementation of the entire program's phases.

    Rationale:

    Evidence was given that the volume is often too great to make all of the calls within forty-eight (48) hours of discharge and Public Health does not have sufficient nurses to staff the program due to nursing shortages in the province. Increased funding for staffing is necessary to ensure continuance and full implementation of this vital program. The program should be mandatory and home visits should be implemented in all cases where significant risk factors are identified.

  41. We the jury recommend, that all shelter workers should be precise in describing to outside agencies the services that their shelter can provide. In particular, if a shelter employs persons who have nursing experience but did not employ those persons to deliver nursing services, then the shelter's workers must be sure not to say anything which might create the mistaken impression that the shelter offers nursing services.

    Rationale:

    Two (2) shelter workers, with nursing experience, were hired as counselors but the mistaken impression was given that nursing services were offered. This created a false security with the social worker and mother of baby Jordan.

  42. We the jury recommend, that programs like "Healthy Connections - Community Programs" which reach out to various communities within Toronto by medical practitioners, continue to be recognized and supported by all levels of government.

    Rationale:

    Evidence revealed a practical medical outreach program which is already in place and which has worked well.

  43. We the jury recommend, that the Public Health Departments and "Healthy Babies, Healthy Children" programs should provide outreach on a regular basis to Youth Shelters and Women's and Family Shelters, which provide residential services to women and children to ensure provision of:
    • Health education
    • Routine health assessment
    • Effective linkages and referral with other medical professions.

    Rationale:

    The special needs and circumstances of this population must be addressed in order to ensure that appropriate health care is available.

  44. We the jury recommend, that the Chief Coroner's office within one (1) year of the anniversary date of this inquest provide a report on the implementation of the above recommendations.