After two and a half days, the coroner’s inquest into the death of 14-year-old Brandon Schafer-Kovacs concluded Wednesday, with the jury making four recommendations to the Eagle’s Nest Youth Ranch group home where he had been staying.
Schafer-Kovacs died in November 2022 at the Jim Pattison Children’s Hospital in Saskatoon from sepsis.
The beginning of the inquest’s third day saw witnesses from the province’s Ministry of Social Services take the stand, speaking to the oversight and review processes following Schafer-Kovacs’s death.
Erin Gagne, who was part of the ministry’s quality assurance team during that time, testified that suggestions were made for the group home in Saskatoon. The Saskatchewan Advocate for Children and Youth also made recommendations for the guidelines all youth group homes in the province need to abide by. The ministry drafted new proposals, which are currently before the advocate.
This means no recommendations from the ministry have been put into effect since Schafer-Kovacs’s death. The group home has since implemented its own policy changes, but is not required to notify the ministry of changes — they only have to be in line with the Residential Services Manual.
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The jury was then charged with coming up with recommendations, and determining what ultimately led to Schafer-Kovacs’s death. After only a few hours, the jury came up with four recommendations for Eagle’s Nest:
- All mandatory training must be signed by the employee and the manager’s supervisor, with a copy provided to the Ministry of Social Services.
- All employees must receive sensitivity training in order to understand the needs of the children in their care.
- Clear separation must be established in client-focused activity logs, which must be kept distinct from house operations.
- All group home staff must document all interactions with anyone outside the home, including members of the ministry.
Coroner Blaine Beaven also recommended that the ministry review recommendations and ensure they fit within the Residential Services Manual.
Before the recommendations were made, Schafer-Kovacs’s family spoke to media.
“I just wanted to say that we miss him terribly and loved him dearly and that his life mattered,” said Cathie Pocha, his grandmother.
Christine Libner, counsel for the family, said they hope for a quick implementation of the recommendations.
“The inquest has provided a lot of insight into the difficult and upsetting circumstances of Brandon’s last 10 days of life and it’s left the family feeling a lot of sorrow and grief that they’re still processing,” Libner said.
Beaven had stressed the importance of jurors’ ability to come up with recommendations based on the evidence and testimony presented, adding he hopes the recommendations put forward will help prevent a child’s death like Schafer-Kovacs’s from happening again.
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Jury makes recommendations following coroner’s inquest into Sask. boy’s death in care
