A coroner’s jury has delivered its findings after three days of testimony into the death of 14-year-old Brandon Schafer-Kovacs. The teen died in the care of the Ministry of Social Services while living in a Saskatoon group home.
The six-member jury concluded Schafer-Kovacs died from sepsis at Jim Pattison’s Children’s Hospital on Nov. 28, 2022. Sepsis is a life-threatening condition that occurs when the body has an extreme reaction to infection.
“I just want to say that we miss him dearly, we loved him dearly — and his life mattered,” Cathie Pocha, Schafer-Kovacs’s grandmother, told reporters following the conclusion of the coroner’s inquest on Wednesday.
The family hopes the recommendations will prevent other families from experiencing similar heartbreak.
“It’s left the family feeling lots of sorrow and grief, that they’re still processing,” said Christie Libner, the family’s lawyer.
Schafer-Kovacs was living at Eagle’s Nest Youth Ranch in Saskatoon before he died, and the jury heard over three days of testimony that while the teen was sick and there was a documented request that he go to the hospital, he wasn’t taken to hospital for several days.
By the time he was taken to the Jim Pattison Children’s Hospital, he was already critically ill. Schafer-Kovacs died three days later in intensive care.
The jury made recommendations directed at the youth home that included mandatory training that’s documented and signed by the supervisor and manager, sensitivity training and clear separation of reporting between client activity logs and house operation logs. The jury also recommended that group home staff document all interactions and communications with outside persons, including Ministry staff.
In addition, Coroner Blaine Beaven made a recommendation directed to the Ministry of Social Services that it consider amending the residential services manual, and forward the jury’s recommendations to all group homes that it contracts with.
Jury makes recommendations after inquest into death of teen who died in care of Sask. Social Services
A coroner’s inquest cannot assign blame, but its goal is to prevent similar deaths in the future. Twelve witnesses testified, including Schafer-Kovacs’s mother, staff from the youth care home, doctors who treated him at the hospital and officials from the Ministry of Social Services.
Among the final witnesses on Wednesday was David Smith, executive director of community services with the Ministry of Social Services. He said a quality assurance review after Schafer-Kovacs’s death has already led to amendments to the Ministry’s policies.
However, Erin Gagne, director of community response services with the Ministry, testified the amendments are still in draft form, nearly three years later.
She said amendments to the residential services manual — including requirements for medical supplies, documentation of illness and staff training — have not yet been implemented across the province.
“Each group does their own policies as long as they fall within the guidelines of the ministry,” she said.
Gagne said the Ministry expects that group homes comply with training requirements but officials do not go out and check if all care homes are fully compliant, aside from yearly audits or if a concern is raised.
