Domestic violence was a part of Christian Lee's all-too-short life. He watched as his father punched his mother in the face and threatened her with a knife.
His mother reached out for help: to police, lawyers, social workers and therapists.
By the time six-year-old Christian's father slaughtered the boy and his family in September, 2007, there were dozens of professionals who might have recognized the danger - had they only talked to each other.
"Christian's murder was not inevitable," concluded Mary Ellen Turpel-Lafond, B.C.'s Representative for Children and Youth.
Ms. Turpel-Lafond yesterday released the first report on the Oak Bay murder-suicide that left five dead. She found a safety net with gaping holes and blamed not the many individuals who were connected with the case, but a provincial government that has not co-ordinated domestic violence programs or given teeth to family law.
Social workers, medical staff, officers from three different police departments, Crown counsel, therapists and lawyers were among those who knew of Sunny Park's fears. She warned that her estranged husband might kill the boy and pleaded for protection.
Navigating an unfamiliar system in a language she struggled to comprehend, she heard conflicting advice on how to safeguard against Peter Lee in her final six weeks as he stalked her while under a court order to stay away.
"Sunny confided a history of escalating violence and abuse. Despite her desperate dread that she would be murdered, responsibility for her safety plan was placed solely on her shoulders," Ms. Turpel-Lafond wrote. "Christian was not safe because his mother was not safe."
Although police were first alerted to the domestic violence in the family in 2003, it was a car accident in July, 2007, that raised alarms about a serious, escalating risk.
Ms. Park, after being questioned by an emergency-room worker, told police she believed Mr. Lee tried to kill her by driving the family vehicle into a utility pole.
As a result, Mr. Lee was arrested and charged. Police were so alarmed after interviewing Ms. Park that they met with Crown prosecutors and asked that he not be released on bail.
But he was released on $5,000 bail, with conditions that he not go to the family home or business - leaving him homeless, destitute and suicidal.
Mr. Lee broke into the family home on Sept. 4, 2007 - just hours before Christian would have started Grade 1 - and killed his boy, his estranged wife and her elderly parents with a knife in a frenzied attack.
He then killed himself.
Had the different agencies involved acted together, operating under coherent domestic violence policies, it is possible Christian would be alive and joining his classmates in Grade 3 this month, Ms. Turpel-Lafond concluded.
"Christian Lee was a victim of domestic homicide, and he was repeatedly exposed to domestic violence over the course of his short life. ... Had he been in a safe environment, matched to the degree of risk, his death may well have been prevented."
Shashi Assanand, an expert in violence within immigrant families, said yesterday it took extraordinary courage for the Korean-born Ms. Park to break through language and cultural barriers to tell anyone about the escalating violence she was experiencing.
"Throughout her time, she was very brave and nobody took her seriously enough to take her hand and say, 'I'm going to take you here.' " Instead, she was directed to multiple police departments and left to navigate a legal system that her husband proved skilled in manipulating.
It's unclear whether the report will produce change: While Ms. Turpel-Lafond was holding her news conference demanding more money and resources to improve the system, the provincial government issued a news release trumpeting its current services for domestic violence.
The watchdog, however, said the system must be changed. In the past five years in B.C., she estimated, there have been 70 deaths resulting from domestic violence, mostly women and children. Collectively, the different agencies involved failed Christian and others continue to be at risk.
"It is not possible to say that ... a single responsible professional in one of those systems could predict that Peter was going to embark on a murderous rampage," she wrote. But with a better system, they might have.
"The tremendous risk of harm to Christian was not fully appreciated by those who were in positions of authority because the necessary structural components to do the work of assessing and protecting were not in place.
"Yes, we failed Christian."
Recommendations from Honouring Christian Lee: No Private Matter - Protecting Children Living with Domestic Violence:
To the Minister for Children and Families Implement changes to B.C. laws and training standards to provide social workers with clear direction in assessing the safety of children who are exposed to domestic violence. "Legislation should specifically acknowledge the increased risk to children when family violence is present." A new provincial training curriculum on working with families in domestic violence must be provided to social workers. Currently, new social workers receive just one day of training on the subject while those already on staff rely on experience alone.
To the Minister of Public Safety and Solicitor-General Take the lead in efforts to develop a "co-ordinated, effective and responsive system" for addressing domestic violence. The report makes recommendations that touch on three distinct agencies of government, and the report's author wants a single point of accountability for implementing change.
To the Attorney-General Create domestic violence courts, which exist in other provinces, to bring specialized expertise to a unique and complex type of crime. "Domestic violence is different from most other crimes because the victim has an ongoing relationship with the offender, they may have children in common, they often own property together, and there may be an economic dependency and cultural and religious pressures to remain in the relationship."