Mere months after a child welfare report raised “grave concerns” that a troubled 10-year-old boy was at risk of harming himself or other children, he beat a six-year-old foster child to death.

Miscommunication, service gaps, missteps, and missed opportunities – those were just a few of the problems the Children’s Advocate identified in a damning report tracing how the child welfare system failed two children.

“It’s a disaster: A child died and another life is changed forever,” Bob Pringle, Advocate for Children and Youth, told a news conference Wednesday. “This is a death that may well have been preventable,” Pringle added.

Titled Two Tragedies: Holding Systems Accountable, his 42-page report examines the child welfare services both children received before their paths crossed with dire results on Aug. 21.

The Advocate for Children and Youth Act prohibits staff from disclosing names, so the children are referred to in the report by the pseudonyms “Sam” – the younger child – and “Derek.” However, the deceased boy has previously been identified by RCMP, with the consent of his mother, as Lee Allan Bonneau, a shy and quiet child who liked to play with a remote-controlled airplane, favoured math and art, and often carried a stuffed animal.

The youngest of six siblings, Derek was considered “bright and joyful,” and enjoyed math, toy cars and video games.

Both Lee and Derek were vulnerable kids requiring special care.

Bonneau was having behavioural problems in school, and questions were raised about physical signs of possible abuse. Concerns for his mother’s mental health prompted child protection workers to apprehend him in June 2013. His mother was put on a waiting list for services. Bonneau was initially placed with family members, but they said they couldn’t care for him over the long term. Five weeks before his death, he was put in his first foster home, then moved to another because the foster mom found his needs too complex.

A case plan that should have been done within 30 days wasn’t completed until after he died.

The last visit he might have had with his parents never occurred because the visiting room at Social Services was booked.

Bonneau was with his foster mother at a bingo on the First Nation on Aug. 21 when she gave him some money to get a treat. She searched for him when he didn’t return after about 15 minutes. The critically injured boy was found some 90 minutes later.

According to RCMP, Bonneau had been beaten with what was described as a blunt force weapon, “something of opportunity.” Too young to be charged criminally, Derek was deemed “a child in need of protection” and taken into care. He remains in a “child resource home,” where a ministry official said he’ll get the help he needs.

Derek and his family had been on the radar of Yorkton Tribal Council Child and Family Services – the designated child welfare agency in his community – since 2008. A boy with a variety of challenges, Derek was diagnosed with Fetal Alcohol Syndrome (FAS), was hearing voices, and, at age eight, was suspected of having helped kill a dog and her unborn pups.

Both his school and the RCMP raised concerns, but there wasn’t adequate followup by the child welfare agency, the report says. Even an agency investigator admitted to the advocate that when he reviewed Derek’s file, he knew the boy was “falling through the cracks.”

The school wanted him kept home because of his behavioural problems, so on March 8, 2013 agency staff made another home visit.

“This was the first documented instance throughout the four and a half years of agency involvement where Derek was actually spoken to by an agency staff member,” Pringle notes in his report.

“We find this is a travesty,” the advocate told reporters, later describing the quality of the casework for Derek as “atrocious.”

For example, although there were nine child protection reports about him, twice there was no documented response.

“In the cases that were investigated, meaningful action by the Agency was severely delayed – often taking place months after the concern was received,” the report notes.

Derek’s third appointment with a psychiatrist occurred more than a year after his last two visits, and a month before he killed Bonneau. Derek’s medication was adjusted to manage his hyperactivity, but there was no documented followup, the report says.

Pringle made 18 recommendations for change – some of them similar to those made in previous reports stretching back decades – including more oversight, better case management, and protocols for more timely services.

To ensure these ones don’t gather dust, Pringle called on Social Services and the First Nation’s child welfare agency to report back to him every three months for the next year on the action taken.

A report by the province’s child watchdog is a study in contrasts – the hope offered by a new Regina program assisting high-risk moms, the despair of two babies’ deaths due to gaps in the child welfare system.

While buoyed by a new risk assessment tool that could help prevent more such deaths, Saskatchewan’s advocate for children and youth Bob Pringle remains worried social workers with high caseloads won’t have the ability to use it properly.

“They need to get a handle on this issue – and fast,” Pringle said during a news conference releasing his annual report Tuesday. Social Services Minister June Draude told reporters strides are being made.

“We have decreased the numbers of caseloads. They went down about 23 per cent in the last number of years,” she said. “We’re going in the right direction, but we know that there’s always more work that we can be doing.”

In the cases involving the two deaths, from 2006-07, profiled in the report, workers cited workloads in excess of 40 cases. Draude said 80 per cent of child protection workers now carry a load between 15 and 20 cases, although in some of those the needs are higher.

In a province with the highest rate of First Nations children living in poverty, Pringle also took the government to task for its failure to have an over-arching antipoverty strategy. Saskatchewan and B.C. are the only provinces without one.

He said poverty and the social conditions that it can spawn, including addictions, family violence and poor mental health, result in children coming into care.

“We are reaching far too many children far too late,” he said.

“If we continue not to address major risk factors, not that much is going to change,” Pringle said. “We’ll continue to pick up the pieces.”

Draude said there are two strategies currently underway that will have an impact on poverty – one on mental health and addictions and the other on disabilities.

“It will help formulate the next steps,” Draude added.

Pringle’s report profiles the deaths of two children born to drug-addicted mothers. “Our child protection system left these vulnerable children in high-risk situations,” the report says. Gaps and non-compliance with policy contributed to the deaths at the hands of their mothers when the children were returned to their care without proper monitoring and support, it says.

A seven-month-old girl died from injuries. In the other case, a 16-month-old died from a treatable skin infection, but there were also other signs the girl had endured months of physical abuse and neglect.

Pringle cited caseloads and communication failures, but those concerns have been repeatedly raised by children’s advocates going back to the first one in 1998 to examine the death of a child in the province’s welfare system.

While admitting he’s “not happy” some of these same issues keep arising, the advocate said he has more reason to hope that there will be some resolution based on discussions with Social Services. He also applauded a new residential facility called Raising Hope that opened last fall in Regina to assist pregnant women who were likely to have their babies apprehended due to high-risk behaviours.

For the first time, the annual report contains statistics on the number of child deaths and critical injury reports received by the advocate’s office in the previous year. Past reports gave numbers for cases “cleared” by the office in a given year, but the deaths and injuries didn’t necessarily occur within that year.

The report says 26 child deaths and 34 critical injury cases were referred to the advocate’s office in 2013 for an independent review. Those numbers include children and youth who were in care of or in receipt of social services in the 12 months prior, and incidents involving youths receiving services from the Justice Ministry and Corrections and Policing within the previous 30 days.

Among the deaths, two-thirds of the children were under age five. While the cause of death wasn’t yet available in 10 cases, in the others it included suicide, medical fragility, homicide, sudden infant death syndrome, motor vehicle collisions, fire and illness.