WARNING: This story contains graphic descriptions of a child’s death.
A coroner looking into the death of a seven-year-old girl in Granby, Que., has concluded that the youth protection system as well as the school and health-care networks failed to protect her and by working in silos, everyone involved was ”forgetting the most important person.”
Coroner Géhane Kamel released her findings and a dozen recommendations Wednesday, over six years after the girl’s death in 2019 — which made headlines across the country and sparked reforms of Quebec’s youth protection system.
The girl had been followed by youth protection since birth and it was revealed during criminal proceedings that the young girl was forcibly confined and malnourished.
Her father was sentenced to three years and six months in January 2022. The man’s spouse at the time, and the girl’s stepmother, was sentenced to life in prison in December 2021 without possibility of parole for 13 years after being convicted of second-degree murder and forcible confinement.
Kamel says this tragedy has “shaken us all and forced us to pause and objectively ask ourselves collective questions about the place we give to children in Quebec.”
She says multiple warning signs foreshadowed this tragedy. Analyzing aspects of the girl’s physical and psychological health, family and school life, Kamel describes some aspects of the report as “unbearable.”
Over the years, CBC News withheld the name of the girl due to a publication ban and other legal considerations. Despite the fact she is named in the report, we will continue to withhold her name.
Kamel issued 12 recommendations highlighting the importance of intervening in a timely fashion and consolidating services to get rid of the ”lack of cohesion” among professionals.
In this case, Kamel says the girl had been followed by school staff, several health professionals, including pediatricians and psychiatrists and said the lack of co-ordination ”has compromised the system’s ability to provide comprehensive, child-centred support.”
“The [department of youth protection] cannot be solely responsible for the well-being of children or be blamed when a failure occurs,” the report reads.
“Child protection is one of the most fundamental values of our society. This particularly heinous tragedy, however, is the very antithesis of that value.”
Valérie Assouline, the lawyer representing the family in this case, says the coroner’s recommendations are pertinent. She hopes Quebecers can be reminded of the duty they have toward children.
“We have to listen to our children. We have a child that tried to be heard and that was not heard. There was a lot of adults around that child,” she said.
Quebec Social Services Minister Lionel Carmant says he read the report and agrees there is a need to do more.
“Every time I hear or read about the Granby child, I am shocked,” Carmant told reporters Wednesday. “We are going to implement all of these [recommendations] … slowly but surely.”
Worrisome indicators related to the girl’s well-being were “numerous and consistent,” Kamel wrote.
In 2018, the stepmother, who was on leave from work, was a full-time caregiver. In the months leading up to the child’s death, the stepmother’s text exchanges with the father revealed that she was “fed up.” In other exchanges, she referred to the girl as “rude” and “an idiot.”
Although the stepmother was in charge of the child, social services had very little access to her for follow-ups, found Kamel.
“The question remains unanswered, but it is nonetheless crucial: why wasn’t the child placed with a third party?” she said.
At a news conference Wednesday, Kamel referenced several red flags in the young girl’s file, including the fact that no spontaneous visits were made to the family home.
Police intervened at the girl’s home 24 times between 2012 and the day of her death, said Kamel.
The report states personnel at school had seen the girl eating food out of the trash and said she looked small and thin with a protruding stomach. In one instance, staff had noticed her arriving with injuries that she said were from her stepmother.
Kamel says the young girl was described as an intelligent person whose potential was “masked by difficult behaviours.”
In January 2019, a psychiatrist evaluated her and confirmed a diagnosis of attachment disorder.
Feeling at the end of their rope, the father and his partner resorted to “questionable educational methods,” such as regularly confining the girl to her room, where she would sometimes end up urinating or defecating, Kamel wrote.
The day before her death, on April 29, 2019, the child was found covered in adhesive tape, including her head. Her external airways were obstructed and the cause of death for the young girl was deemed external suffocation, said Kamel.
The father stated that his daughter had severe behavioural problems and that she had run away the previous day. He and his partner had therefore decided to barricade her room for the night.
A provincial police investigation found that the child had been bound with tape, and her mouth was also covered.
When police arrived, after her father called 911, he was performing lifesaving techniques. She was transferred to hospital in the nearby city of Sherbrooke and kept on life support until neurological testing confirmed she was brain dead.
The girl’s death prompted an inquiry into Quebec’s youth protection system which found that it is failing to provide vulnerable children with safe and healthy environments.
This commission recommended adjusting workloads to match the needs of children and families, increasing the number of professionals and reducing their administrative tasks.
Kamel, in her report, said this need remains just as critical in 2025.
Several recommendations were made for the Health Ministry, Santé Québec, the Crown prosecutor’s office and local health authorities.
In a letter addressed to the girl in the report, Kamel says her story is one that grips the heart and “enrages the soul.”
“You left too soon, far too soon taken by injustice and the silence of a world that should have protected you,” wrote Kamel.
“You had the right to grow, to run, to dream, and to laugh with all your heart. You had the right to love, to kindness, to a life filled with tenderness and security. That right was snatched away from you.”
