It would be hard for any parent to read about how a 15-year-old girl with Down syndrome ended up living for days beside the her dead mother's body in a mobile home without coming close to tears.
The girl - and her mother - faced terrible adversity. The system of supports and child protection supposedly in place to prevent such a horrific outcome failed. And the failures came despite repeated warnings that children and families were at risk.
Representative for children and youth Mary Ellen Turpel-Lafond issued a damning report on the case this week. It was clear, she found, that the girl was at risk.
There were repeated warnings - over several years - to the Children's Ministry alleging neglect and signs of abuse.
The mother was also clearly in crisis, a victim of her own addictions, illnesses and poverty.
And both were achingly vulnerable. The girl, at 15, had "moderate to profound" intellectual disability, functioning at the level of a preschooler. She suffered from frequent illnesses, muscle weakness that required ankle and foot braces and needed hearing aids and glasses.
The mother had been in a long downward spiral. She had lost her job. When she had a minor car accident, she could not afford to repair it. She lost her two jobs and her isolation increased.
Once on miserly provincial income assistance benefits, she couldn't afford to buy cellphone minutes, adding to her isolation. And she battled mental and physical health issues, including, according to neighbours, alcoholism.
There are two obvious failures. All children with special needs, and their families, are supposed to receive assistance with assessment, planning and services. That did not happen. The current approach, the report found, requires parents to navigate a difficult, complex system. When they can't, their children suffer.
And this is exactly the kind of case that should trigger Ministry of Children and Families action to protect a child, whether that involves apprehension and placement in foster care or support for the family.
That did not happen. Over almost four years, child protection concerns were raised, without adequate response from the Ministry of Children and Families. Social workers failed to act.
There were warning signs that should have been noted by her school, her doctor, income assistance workers and others. Specific allegations of abuse and neglect were made to the ministry.
But the child ended up in a filthy trailer, hungry and frightened, dehydrated and sick, sleeping beside her dead mother.
The report offered recommendations. The ministry should develop a detailed strategy for providing services to children with special needs.
That should start with an analysis of what is required to provide support to the 11,000 children needing services, the current staffing and resources and a plan to fill the gaps.
It should address serious weaknesses in its approach to assessing risks to children.
And the report noted the government cut off the mother's income assistance just before she died, even though it knew she was struggling, desperately poor and caring for a special needs child. That should never happen without a review and consultation with the Children's Ministry, Turpel-Lafond said.
The government has pledged to accept the recommendations. But it said the same thing about the Hughes report and past representative's reports, and failed to act. It said the same things three years ago, when the representative warned about serious problems in services for children with special needs.
There were, it should be noted, acts of kindness, and workers buying food for the family with their own money.
But they only heighten the systemic failure that resulted in such a disastrous outcome for a vulnerable girl and her equally vulnerable mother.
