Velvet Martin has long sought answers in the death of her 13-year-old daughter.
Samantha Lauren Martin spent the bulk of her life in a Morinville foster home, from the time she was seven weeks old until shortly after her 13th birthday. She then returned to live with her biological family.
Six months later on Nov. 29, Samantha became ill and died at the Stollery Children's Hospital Dec. 3, 2006 after her parents removed life support.
Martin accepts Samantha died of cardiac arrest, but said it was the result of her neglect in foster care.
"We wanted to expose the deficits that are transpiring that are leading to the casualties of these children," she said. "I didn't want Samantha to just be another child that lived and breathed and died and was never recognized."
The final report, dated Oct. 2, will be publicly released by Alberta Justice on Nov. 2.
In it, Judge Marilena Carminati determined the manner of death was natural, but was unable to determine a cause of death.
"The cause of death may well have been a seizure, but due to the absence of evidence, it is not possible to say that this was the probable cause of death," she said.
The report says roughly 21 per cent of children with Samantha's condition, Tetrasomy 18p, a rare genetic condition that leads to various developmental delays, have seizures.
Four basic recommendations were made, all of which are aimed at Children's Services.
These include ensuring caseworkers have a "reasonable" case load and have accurate and up-to-date medical information about the foster child, with awareness of any impact health conditions could have on weight or fragility.
She also recommended Children's Services improve policies to make sure children receive annual medical checkups and said the agency should follow up on medical complaints submitted by reliable sources, like school staff.
"What the judge is really recommending is that employees follow their own policy," Martin said. "It's very sad that we've gone through this process just to find that you should be doing your job."
Face time
Samantha's parents put her into foster care shortly after birth, as they believed she would have better access to medical attention.
The family became increasingly involved in her life, starting when she was three years old. The Martins became Samantha's part-time guardians in 2001 and were set to take over full-time guardianship in December 2006.
Samantha's life in foster care was riddled with red flags, many of which went undetected by her caseworkers.
Samantha's caseworker from 1998 to 2005 was required to have at least one in-person visit every three months. There was a 14-month gap between July 2001 and September 2002 where no visit took place.
She testified that her caseload made it difficult to update paperwork and said two meetings were not documented.
Reports show the previous caseworker only met with Samantha three times over a 26-month period. The last caseworker, who took over in September 2005 did not visit Samantha.
The longtime caseworker said she thought Samantha was visiting her doctor regularly.
Her pediatrician testified he would normally see children with similar medical conditions to Samantha's every three months. He only saw her four times between 2000 and 2004.
Foster care concerns
According to the report, school staff raised concerns about various bruises and fractures, increasing in frequency since December 2005. Samantha's condition made her largely non-verbal, so she was not able to explain her injuries.
There was also concern as to the contents of Samantha's lunch compared to the "larger more balanced" lunches given to the foster parents' biological son.
When school officials raised this problem with the foster mother, she instructed staff to "fill Samantha up with water." At this time, Samantha weighed just 51 pounds.
Her doctor testified her low weight was not related to Tetrasomy 18p and was instead the result of low caloric intake.
A specialized investigator with Children's Services became involved in the case at the beginning of 2006, but determined an investigation was not required.
Just one month after moving in with the Martins full time, Samantha's weight increased by 11 pounds.
Another apparent oversight relates to seizures, which were reported to Children's Services by school staff.
Her long time caseworker starred a note reading "E.E.G. to rule out seizure disorder" in 2002, but did not follow up. This concern was not shared with the foster mother or Samantha's pediatrician because the caseworker said she thought they were already aware of the problem.
A doctor testifying at the inquiry said untreated seizures can lead to greater risk of death.
Samantha's name was originally protected under a publication ban due to her status as a foster child, however, her mother fought to have the ban revoked.
Martin said she would like to see publication bans lifted to expose conditions leading to death in foster homes. She said she intends to seek criminal charges.
"What I want to see is closure of the home so that no other children die and that the caseworker be removed from her position," she said. "I don't want anyone else to suffer the loss that we have."
