Introduction

1. Nunavut has the youngest and one of the fastest growing populations in Canada, with people under the age of 15 making up more than 30% of a population of about 40,000 Nunavummiut. The well‑being and safety of these young people and their families and community endure as core Inuit values. They are reflected in Inuit societal values, including Pijitsirniq, which means serving and providing for family or community, and Inunguqsainiq, which means nurturing or raising an individual to be a productive member of society as stated in the Child and Family Services Act.

2. In Nunavut, intergenerational trauma resulting from colonialism and residential schools, compounded by social and economic challenges such as inadequate housing, food insecurity, poverty, and remoteness, creates a complex range of issues that put some children and families at risk and in need of child protection and family services.

3. In 2014, we conducted a follow‑up audit focused on the progress made by the Department of Family Services on key deficiencies found in our 2011 audit of child and family services in Nunavut. The 2014 audit found that the department made unsatisfactory progress in complying with key child protection standards and ensuring ongoing human resources capacity to fulfill its mandate.

4. The audit examined whether the Department of Family Services and the Department of Health, with the support of the Department of Human Resources, provided services to protect and support the well‑being of vulnerable children and youth and their families in accordance with legislation, policy, and program requirements from 1 January 2019 to 31 May 2022.

5. More details about the audit objective, scope, approach, and criteria are in About the Audit at the end of this report.

6. The Department of Family Services is responsible for delivering programs and services related to child and family services, poverty reduction, income assistance, and career development. Within the department, the Family Wellness division provides support services for children, youth, and vulnerable adults who may require protection or other specialized support. The division assists individuals, families, groups, and communities to develop skills and make use of both personal and community resources to enhance their well‑being.

7. The Health Care Service Delivery Branch of the Department of Health provides clinical services at community and regional health centres and at the Qikiqtani General Hospital in Iqaluit. In terms of child protection, the department’s nurses provide care to children and youth who have experienced abuse and neglect. The branch’s Mental Health and Addictions program has a mandate to provide a person-centred, comprehensive continuum of care to those individuals and families experiencing emotional distress or psychiatric disorders.

8. The Department of Human Resources’ staffing division works in collaboration with government departments to develop and implement recruitment initiatives. The department is the lead in allocating the Government of Nunavut staff housing.

Early Findings

Letters to senior management

9. Our early findings during this audit on child protection services were so alarming that we brought our concerns to the Department of Family Services’ attention without delay.

10. We issued a first letter to senior management of the Department of Family Services in December 2022. We informed the department that we found limited or no evidence that it had investigated many referrals of child abuse and neglect. We also informed the department of our concerns about many significant gaps in its case management and supervision of children and youth under its care, including children and youth in foster homes. Without evidence that the department had responded to referrals, and given the gaps we identified in case management and supervision, we were deeply concerned that some children and youth did not receive the protection and services they needed and were entitled to under the Child and Family Services Act.

11. We identified 47 cases for follow‑up, involving 92 children and youth. In 42 cases (85 children and youth), we identified possible follow‑up actions the department could consider—including face‑to‑face follow‑up with the young people involved in the cases—because we were concerned that their safety and well‑being could still be at risk. For the remaining 5 cases (7 children and youth), we requested documentation related to key steps in the departmental standards that was missing from files. In March 2023, the department provided us with information on the actions it took in response to our concerns:

• In 48% of cases (20 of the 42 cases involving 36 children and youth), the department responded that it had followed up and that there were no concerns regarding the safety and well‑being of the children and youth we identified. We received no evidence to support those statements.
• In 33% of cases (14 of 42 cases involving 33 children and youth), follow‑up actions were underway.
• In the remaining 19% of cases (8 of 42 cases involving 16 children and youth), the department did not provide any information about its follow‑up on the children or youth in question.

12. Overall, it is our view that the department’s responses to our concerns did not alleviate our unease about the safety and well‑being of all the children and youth we had identified. The department needs to introduce long‑term and sustainable improvements to its process of responding to reports of suspected child abuse.

13. The concerns and possible follow‑up actions we put forward for consideration were based on information we received from the department. The department remains responsible for determining the appropriate action in the instances we identified.

14. We issued a second letter in March 2023, in which we raised concerns over how the department manages the health and safety of its employees. We noted that the department had neither a health and safety program nor a workplace violence policy.

15. Despite evidence of incidents of physical assault, verbal abuse, and threatening behaviour against workers, we found that the department did not have a system in place to collect and manage occupational health and safety incident reports.

16. The department told us that it does not have the resources at this time to address these gaps. We are very concerned that the department’s lack of required protection places frontline workers at risk.

Findings

Referrals to family services

Failure to act on reports of suspected harm

17. We found a number of significant deficiencies in how the Department of Family Services responded to reports of suspected harm and how it supported children and youth in foster care as well as those placed in care facilities outside of the territory. We identified a number of long‑standing issues that in our opinion contributed to those deficiencies. These issues relate to funding, staffing, housing and office space, training, and management of files. They are discussed starting at paragraph 38.

18. Employees of the department are required under the Child and Family Services Act to respond to cases where a child may be in need of protection. These referrals can be reported by, for example, nurses, police officers, teachers, family members, or neighbours. Under the department’s standards and procedures, community social services workers must screen all child and family referrals received by the department to determine whether there are possible child protection risks or whether families have other needs. In our sample of 51 case files across 5 communities, there were 92 such referrals. We found that in 20 of the 92 referrals we examined, the department did not do a screening of the child’s risk and circumstances (Exhibit 1).

19. Of the 72 referrals that were screened, 60 were determined to require investigation. We found that investigations were not started in 15 cases out of the 60 (25%) referrals that we examined. Furthermore, another 15 (25%) were started but not completed.

20. The failure to complete required steps for screening and investigation of a referral means that vulnerable children and youth could be left at risk. We saw very little evidence that supervisors were verifying that required steps in the process were being completed. In addition, when investigations are not concluded, this means that protective services are not being provided to children who might be at risk of maltreatment. These failures are also missed opportunities to assess whether families require support such as parenting, mental health, or addictions services.

Protective services

Little action on plans of care

21. After the Department of Family Services completes an investigation, it has several options for actions to protect children and youth who are determined to need protection. A plan of care is frequently used as a means to keep a child safe within the family home or in foster care, and it is an alternative to the department seeking a child protection order from the court. The plans, which may be extended, are signed by a number of stakeholders, including the department and the person with custody of the child. These plans may include, for example, terms for support services, counselling, or visitation by a parent who may not be living with the child.

22. In 51 case files that we looked at, there were 41 plans of care in place during our audit period. We found in 36 of the 41 plans of care (involving 27 children and 13 families) that the department did not have evidence that the terms of the plans were carried out. Without follow‑up on these care plans, there is no way to know if the issues that gave rise to child protection concerns are still present. This could leave children exposed to further risks.

23. For example, we found a case of a very young child who the department assessed as needing protection due to physical abuse by a parent. The plan of care in the department’s files stated that the child would remain at home and the parent was required to access mental health counselling. However, we found that the department did not follow up on the plan of care and did not contact the child and parent for a year and a half. The department followed up only after it received another report of physical abuse involving the same parent and child. The department set up a new plan of care and placed the child in foster care, but again did not follow up on the child’s safety and well‑being afterward. In our opinion, this is an example of multiple failures: The system failed a child who had been harmed, and failed to help a parent acquire the skills to change a pattern of harm.

24. We also found that some programs and services (such as alcohol and drug counselling, and parenting programs) that were needed to help families were not offered at all by the departments of Health and Family Services in some communities. In others, the programs and services were offered only temporarily, for short periods of time.

25. Furthermore, the Department of Family Services, the Department of Health, and other stakeholders acknowledged in the 2020 Surusinut Ikajuqtigiit: Nunavut Child Abuse and Neglect Response Agreement that collaboration and sharing information are vital for making informed decisions about the protection, safety, and well‑being of children and youth. In 1 community we visited, we found local supervisors had established regular meetings between the Department of Health and the Department of Family Services to discuss individual cases.

Foster care

Lack of oversight and required screening

26. During the period of our audit, the Department of Family Services did not have reliable data on the total number of children and youth in foster care. As of August 2022, the department indicated that there were 180 children and youth in foster care in Nunavut and that there were 140 approved foster homes in the territory. As a result of the gaps and weaknesses in information management that are discussed in paragraphs 56 to 59, we could not confirm the accuracy of these numbers.

27. Removing children from their homes and placing them with extended family or unfamiliar caregivers in foster care or in group homes is done in exceptional situations to safeguard the children’s mental and physical well‑being.

28. In our sample of 51 files, there were 26 children placed in 15 foster homes. We found that the department did not have evidence of check‑ins with any of the children or the foster homes as required. Monthly check‑ins at the foster home, by telephone or in person, are required, as are private, face‑to‑face meetings with children every 6 weeks. Alarmingly, we found that the department had no evidence of contact with the children or the foster home for extended periods including

• gaps of 6 to 8 months for 8 children in 4 of the foster homes we examined
• no check‑ins on 10 children in 6 foster homes for 12 months or more, including 2 foster homes with no check‑ins during the 39‑month period of our audit

29. In the absence of check‑ins, the department did not know about children’s well‑being or safety, or their whereabouts, what kind of care they were receiving in their foster home, or whether the foster home was receiving any required support. For example, we found that:

• The department learned that 2 children it had not contacted for 4 months were no longer in their foster placement and were living elsewhere.
• The department learned that 2 children who were temporary wards of the department were once again living with the parent who had lost custody of them. The department learned about this a month after the children were back with the parent. Nothing on file indicates that the department took action to ensure the safety and well‑being of the children afterward.
• There was no evidence that the department took action when it received information that 10 children in foster care were experiencing suicidal thoughts or had attempted suicide, or were at risk of sexual abuse or physical harm.

30. We selected an additional 6 foster homes for a total of 21 foster homes across the 5 communities. Of these, 12 were new. We found that the department did not thoroughly screen these new homes (Exhibit 2) or carry out required reviews of the established ones. Screening new foster homes and monitoring established ones are essential to confirming a safe and stable environment for children.

31. We also found that the department did not direct community social services workers and supervisors on what to do when the results of criminal or vulnerable sector checks had positive or possible matches. In 6 of the foster home files we examined, the department approved and continued foster placements where adults in the foster home had criminal record matches. We found only 1 of these 6 homes where departmental employees contacted the Royal Canadian Mounted Police in order to confirm whether a criminal record or other record existed.

Out of territory

Few check‑ins on children and youth

32. When services are not available within the territory’s 25 communities or when exceptional circumstances warrant it, an option for children, youth, and young adults (aged 19 to 26 years) is to be placed in care outside of the territory. Placement out of territory includes both for foster care and special needs. Removing young people from their homes, schools, and communities—from the Inuit culture and land—requires tremendous consideration and care. The impacted children are at risk of losing their culture and identity. Their placement must be one that provides the children with a living arrangement that will support their physical, mental, and emotional well‑being.

33. We received information from the Department of Family Services that 95 young people were under the department’s care living out of territory as of March 2022 (Exhibit 3). In the files we reviewed, children, youth, and young adults were placed in Alberta, Manitoba, and Ontario. As a result of the gaps and weaknesses in information management that are discussed in paragraphs 56 to 59, we could not confirm the accuracy of these numbers.

34. We only found evidence for 1 out of 23 children, youth, and young adults that the required quarterly case reviews with the care providers in southern Canada were done. Apart from this, we did not see evidence that community social services workers from the home community were checking in on a monthly basis with young people as required. Though children, youth, and young adults may have had contact with Inuit client liaison officers or family members during this period, this remains an example of the Department of Family Services failing to take actions that it is required to take. Follow‑up contact with young people placed out of territory would help determine when, or if, they can be brought back to Nunavut and be reintegrated into their culture and communities.

35. We also found that the Department of Family Services could not demonstrate that it had completed, monitored, and tracked annual site reviews for all out‑of‑territory care provider facilities. These reviews confirm whether the facilities are meeting safety and licensing requirements.

36. We also found that the department lacked policies and requirements for important aspects of its out‑of‑territory services. For example, the department recognized the need for it to have Inuit employees in provinces to support children and youth who were in placements out of territory. Inuit client liaison officers are now based in Alberta, Manitoba, and Ontario. However, we found that client liaison officers lacked direction and training on how to support Nunavummiut, and their roles and responsibilities were not clearly defined. In addition, the department did not have a process to regularly review when out‑of‑territory children and youth could be repatriated back to Nunavut.

37. In 2016, the department committed to developing a continuum of services care strategy to keep children, youth, and adults in the territory and bring back those who were placed in facilities in southern Canada. We found that 6 years passed before the department started, in the fall of 2022, to discuss the strategy with stakeholders.

Root causes

38. We found that the Department of Family Services’ inability to meet its responsibilities to Nunavut’s at‑risk children and youth is linked to many intertwined root causes that have contributed to this persistent and chronic crisis. They include funding, staffing, lack of housing and office space, lack of timely training, and poor information management. Our findings in this report echo those of our audits in 2011 and 2014. Employees will not be set up to perform well in their jobs until the department has adequate resources and provides them with the appropriate tools. Over time, the department has repeatedly committed to addressing our recommendations, yet the crisis persists. These interlinked root causes will need to be addressed through interdepartmental collaboration. That will require the government to oversee a whole‑of‑government approach.

Funding

39. We found that the Department of Family Services’ budget and expenditures were stable from the 2018–19 to the 2021–22 fiscal years. Annual expenditures averaged $161.6 million (Exhibit 4). The budget for the 2022–23 fiscal year was $169.6 million, increasing to $179.5 million in 2023–24.

40. As per the Government of Nunavut’s 2023–26 business plan, the Family Wellness division’s budget for the 2021–22 fiscal year was $75 million. Of that total,

• the budget for the child protection, family violence, and foster care programs was $25.5 million (34% of the Family Wellness division’s budget)
• the budget for facility‑based care, including care provided to children and adults within Nunavut and outside of the territory, was $43.7 million (about 58% of the division’s budget)

41. We found that the department submitted some business cases to increase the number of positions in the Family Wellness division. Between January 2019 and May 2022, the department gained a net of 9 Family Wellness positions. Of the new positions, only 4 were filled by May 2022.

Staffing

42. In May 2022, within the Department of Family Services, the staffing vacancy rate was 49% in the Family Wellness division. We found that community social services workers often are on short‑term contracts, with frequent turnover. In 2022, an average of almost 56% of community social services workers were in short‑term contract positions in Nunavut. The prevalence of short‑term employees leads to a lack of continuity of services, a need for timely training sessions, and increased workloads for supervisors and experienced colleagues. Permanently filling vacancies is required to provide stable, continuous services to vulnerable children, youth, and families. We found that Inuit representation among community social services workers was low. At the end of May 2022, 14 out of the 47 permanent and casual community and social services worker positions were filled by Inuit staff.

43. To identify children at risk, investigate cases, and respond when children need protection, community social services workers and supervisors are needed for carrying out these tasks. Yet we found that some communities went months without a community social services worker during our audit period (Exhibit 5). This included large communities such as Igloolik, with a population of over 2,000. During our audit period, Igloolik had only a single community social services worker for 18 months and had no community social services workers at all for 4 separate months. Clyde River, with a population of more than 1,000, had no community social services worker for 23 months of the audit period. We also found that 8 communities with populations of 1,000 or more spent 18 or more months in that time period with only 1 community social services worker, which would have left any individual working alone on call almost permanently.

44. The Department of Family Services did not collect and analyze data on the caseload of community social services workers. Their responsibilities include screening referrals, conducting investigations, screening foster homes, monitoring children in foster care and out of territory, and attending court, among many other duties. Without a detailed workload analysis, the department cannot reliably determine how many community social services workers are needed in each community.

45. One of our recommendations in 2014 was to fill community social services worker positions with permanent employees in all communities. However, the department continues to hire workers on 4‑month contracts, and these casual workers are primarily from outside of Nunavut. Between January 2019 and May 2022, the department employed a total of 103 individual casual community social services workers. The majority—79 (77%)—came from outside the territory. These workers need the department’s support to become oriented to the work required and to the communities, culture, and language.

46. Inuit employees in the Family Wellness division, like family resource workers or interpreters, enhance social services and lessen the workload of community social services workers through their knowledge of Inuit culture, languages, and the communities. We found that up to 8 communities spent half or more of the year without any Inuit Family Wellness employees between 2019 and 2022. We found that at the end of May 2022, only 5 of 10 family resource worker positions were filled with permanent employees, and there was 1 family resource worker on a casual contract.

47. We also found that the percentage of positions occupied by full‑time supervisors has decreased steadily. In 2019 and 2020, the 12 funded supervisor positions in the department’s Family Wellness division were filled an average of 73% of the time with permanent employees. This fell to an average of 51% in 2021 and remained low at 50% in the first 5 months of 2022. There was no information available to explain this decrease.

48. We also found chronic shortages of Department of Health frontline health care and mental health and addictions workers: In the first 5 months of 2022, the average vacancy rate was 46% for frontline health care workers, and 68% for mental health and addictions workers. Staffing shortages resulted in reduced service levels in community health centres.

Staff housing and office space

49. We found that recruitment delays were attributable in part to staff housing requests that were pending for 6 months to 2 years. Although access to staff housing units was insufficient in many communities, the Department of Human Resources did not assess what staff housing was needed in each community.

50. In the 2021–22 fiscal year, the Department of Family Services identified 13 communities in which its offices needed repairs or additional space. In several cases, lack of office space resulted in employees working in space borrowed from the Department of Health, or in overcrowded spaces. Community social services workers need to have a workspace that allows them to interact with children, youth, and their families in a safe and confidential manner.

Lack of training

51. Department of Family Services. The department had a mandatory 5‑day core training for community social services workers and 5‑day training—StepWise 360—on techniques for interviewing children who may have been victims of abuse. We found that the median number of months casual and permanent workers waited from starting employment to receiving core training was about 10 months, and about 19 months before the department provided training on interviewing techniques.

52. Because the department is addressing vacancies by hiring casual employees on 4‑month contracts, some employees never received the mandatory training at all. The situation may create risks that employees are not equipped to carry out their work to protect children.

53. In addition, the department had only 1 position to do all the scheduling, booking of space, documenting of files, and travel arrangements related to training. The position was filled for only 21 months of the audit period.

54. Department of Health. Training can also help frontline health care providers such as nurses correctly identify child maltreatment when children are visiting health centres. They are frequently the first to witness signs of child abuse, harm, and neglect and are legally required to report cases where they believe a child needs protection.

55. We found that the Department of Health provided orientation training on child welfare topics, such as when to report on cases of child maltreatment and to whom cases should be reported. However, it acknowledged that more training and guidance were needed in this area.

Ineffective information management

56. Ineffective information management is another root cause of the failures in child and family services. Having access to reliable, accurate, up‑to‑date information in a central system—and training staff to use it—is essential for continuity of knowledge and informed decision making. Information and the means to access it provide frontline workers with what they need to carry out their work. This includes information such as where vulnerable children and youth are living, their plans of care and past history, and whether necessary follow‑up visits are being conducted.

57. Following our 2014 audit, the Department of Family Services developed a new online system for managing information. However, the department subsequently determined that the system did not meet its needs; for example, for aggregating and reporting data. The department procured a new system in 2022, which it plans to have implemented later in 2023.

58. In this audit, we found that the Department of Family Services was not meeting its own standards on records management nor did its information management practices comply with the Government of Nunavut’s policies on record management.

59. We found that each of the 5 communities we visited had different approaches to managing their case files. Some communities kept paper files; some kept electronic files on individual computers, universal serial busUSB keys, or in the department’s existing case management system; and some combined methods. In some communities, we also found that files—such as paper copies and USB keys—were not stored in a way that would protect confidentiality.

Conclusion

60. We concluded that the Department of Family Services consistently failed to take action to protect and support the well‑being of vulnerable children, youth, and their families in accordance with legislation, policy, and program requirements. In addition, the Department of Health and the Department of Human Resources have not provided needed support and resources, such as in the areas of training, staffing, and staff housing.

61. Our findings are more than statistics, trends, and a compilation of facts. This report is a call to action. To protect the territory’s vulnerable children and youth, solutions lie in a whole‑of‑government approach to overcome the challenges in serving Nunavut’s 25 communities. We ask that the Government of Nunavut act to compel the departments of Family Services, Health, and Human Resources to collaboratively take urgent and necessary concrete actions to help safeguard Nunavut’s children, and support the territory’s families and communities.