System failed Matthew Rich, dead at 4 months, and sibling, report says

The death of Matthew Rich has highlighted problems with the care and protection of children that have not been fixed despite dozens of recommendations over the years, says Newfoundland and Labrador's Advocate for Children and Youth.

Carol Chafe delivered her report on the investigation into the four-month-old baby's death in 2013 today in St. John's. Although the report uses pseudonyms for the family involved, Rich's family has spoken to CBC about the tragic loss of Matthew, as well as a loss of evidence that resulted in charges being dropped against the baby's alleged killer — Matthew's father Thomas Michel.

• Brain that was evidence in Labrador infant death case likely thrown out with medical waste, docs show

Rich, of Sheshatshiu, was brought to the hospital in Happy Valley-Goose Bay on Oct. 15, 2013 in serious condition, but died later the same day.

"Additionally, [Rich] will never receive the justice of having someone held accountable for his stolen life because government services did not ensure that his right to justice was upheld," Chafe's report noted.

The loss of evidence in Michel's case has resulted in an external review of the province's Chief Medical Examiner's Office. 

'Government services failed to meet their needs'

Chafe began her investigation into the services provided to Rich and an older sibling in 2014.

The report, A Stolen Life, is the story of two "vulnerable children and how government services failed to meet their needs," said Chafe in a statement Wednesday morning.

Despite "numerous encounters" with officials in the Department of Children, Seniors and Social Development (formerly Child, Youth and Family Services), said Chafe, they continued to live in an "unacceptable, unsafe environment detrimental to their safety and well-being."

Broken bones

Both children witnessed family violence and substance abuse, the report found. 

Two months before Rich's death, the report said, a source reported that the mother made repeated threats to "hurt and abandon" the baby. 

Rich was taken to hospital six times over the course of one month for respiratory issues, and healthcare professionals noted he appeared healthy and well. 

However, an autopsy of the baby revealed he had sustained multiple bone fractures that did not cause his death, indicating that the injuries happened in the past and had since healed.

183 recommendations since 2006

The report highlights deficiencies in the system, says Chafe, that have existed for years, despite recommendations — by her count, 183 since 2006 — for improvement.

"Once again, the Labrador region is highlighted as one with many challenges, where factors such as environment, workload, and human resource issues have not permitted the necessary changes to occur," said Chafe.

"Every child and youth in the province has a right to receive services provided by the provincial government, and this right to services must be upheld regardless of where in the province they live."

One of the recommendations has to do with the RCMP and the Royal Newfoundland Constabulary's responsibility to deliver child protection reports to government within the right period of time.

Chafe noted that the Department of Children, Seniors and Social Development received a report that Rich's sibling may have been assaulted by Rich's father. But the RCMP didn't let the department know until two days later, when a second RCMP officer reviewed the statement.

She added that it took the RCMP three months to provide the department with Matthew Rich's autopsy results. 

• Murder charge withdrawn against Sheshatshiu father accused in infant son's death
• Matthew Rich murder case: Review called into how infant's brain went missing