Good morning. Wendy Cox in Vancouver.

After a day of deliberation, the five members of a coroner’s jury filed into an inquiry room late Thursday afternoon and delivered 18 recommendations for improving the care given to Indigenous youth. An interested observer might wonder why any agency or government ministry with a mandate specific to giving care to kids like Cree teen Traevon Desjarlais-Chalifoux needed to be told half of them.

But startling testimony over 10 days demonstrated that the treatment given to Mr. Desjarlais-Chalifoux was so far removed from the Indigenous-centred, healing environment he was supposed to receive that jurors felt the need to state the obvious.

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They recommended that the Ministry of Children and Family Development and Xyolhemeylh, the agency delegated by the province to provide care to Indigenous youth, create a policy requiring staff to report when children are missing immediately to the police. Children in care should get the same kinds of cultural opportunities as staff. Workers should take notes when meeting with their clients and those notes should be kept on file. Providers should share information in real time about the client so the whole care team is up to date.

For Rees Family Services, the contractor hired by Xyolhemeylh to run the group home where Mr. Desjarlais-Chalifoux was placed and would eventually die, the jurors recommended that the company evaluate its workers’ “cultural competence” and those workers should be required to demonstrate an understanding of the history of Indigenous Peoples in Canada.

The inquest was called this spring after a Globe and Mail investigation into the death of the 17-year-old, whose body was discovered in his bedroom closet four days after he was reported missing in September, 2020. The Globe found serious deficiencies in the treatment provided by Xyolhemeylh – also known as the Fraser Valley Aboriginal Children and Family Services Society. Xyolhemeylh is one of 24 Indigenous Child and Family Service agencies charged with providing foster care to First Nations, Métis and Inuit children and youth in British Columbia.

Although Xyolhemeylh was set up specifically to provide culturally appropriate care to Indigenous teens, the inquest heard that the workers at the group home where Mr. Desjarlais-Chalifoux was placed had no training on how to treat Indigenous youth and few staff were actually Indigenous themselves. The two white men who traded shifts at the group home run by Rees, which operates nine such facilities in the Fraser Valley area, testified that they were given no formal training on looking after minors who have suffered trauma.

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The B.C. official in charge of reviewing his care for the ministry told the inquest Mr. Desjarlais-Chalifoux’s case revealed that government counsellors helping Indigenous teens in foster care have no standardized way of reporting if their clients were suicidal. The inquest heard that the youth had told his counsellor three weeks before his death that he might harm himself, but the counsellor took no further action after determining the risk was not high.

Trisha Myers, acting executive director of quality assurance in the ministry, testified this week that the province will roll out a new tool kit “in the next couple of weeks” to help counsellors better identify and report if the kids in their care are suicidal.

In other changes, James Wale, B.C.’s acting director of child welfare, said British Columbia will soon begin piloting a new approach to the group homes, ensuring that staff have clinical training and can offer more wraparound support for youth with complex needs.

The coroner’s jury recommended group homes be phased out all together in favour of more supports for families.

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More than two years has passed since Mr. Desjarlais-Chalifoux’s death and it’s unlikely that there would have been public scrutiny of the multi-level institutional failures in his case were it not for Globe reporter Nancy Macdonald’s initial investigation: The coroner’s inquest was called a week after her story was published and 18 months after the teen died.

But the issues revealed during the hearings have added urgency to the need for solutions. This past October, the B.C. government announced it is overhauling its child-welfare system to ensure First Nations are able to assume complete control over the care of their children. The move was hailed by Indigenous groups as an important step forward toward recognizing the principles of the UN Declaration on the Rights of Indigenous Peoples.

The move also means that the provincial government will no longer have a role in oversight and B.C.’s children’s watchdog can get involved only when invited. How standards of care will be monitored under the new system is unclear.

This is the weekly Western Canada newsletter written by B.C. Editor Wendy Cox and Alberta Bureau Chief James Keller. If you’re reading this on the web, or it was forwarded to you from someone else, you can sign up for it and all Globe newsletters here.