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An Indigenous teen who struggled with addiction and died in 2016 did not get the help he needed from social workers, school officials and others, Manitoba’s advocate for children and youth said Friday.

The 17-year-old, who is not identified in Daphne Penrose’s 104-page report, was repeatedly let down in efforts to curb his drinking and drug use, and was left in unsafe homes by social workers who should have known better, she said.

“His story is not uncommon. He was a young Indigenous youth who lived in a First Nations community and the service equity wasn’t there,” said Penrose, an independent officer of the Manitoba legislature.

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Manitoba Advocate For Children And Youth Daphne Penrose addresses a news conference in Winnipeg, Oct.19, 2018.Steve Lambert/The Canadian Press

The boy had a happy childhood by all accounts, her report says, but started having trouble when he found out his father was not his biological parent. He started acting out at his high school, started drinking and doing drugs and pleaded guilty to setting a fire at his school when he was 14.

Even before the arson, the school reacted to the boy’s problems by repeatedly suspending him.

“It is important for schools to employ alternatives to school suspensions whenever possible since … excluding youth from school can increase their risk of experiencing negative outcomes,” the report states.

The boy opened up about his addiction and suicidal thoughts to an addictions counsellor based in the school, the report adds, but his parents were never brought in and appeared to be unaware of the depths of his despair.

Manitoba’s troubled child-welfare system also let the boy down, Penrose said. Social workers failed to properly assess a home where the boy was staying as unsafe. One agency worker wrote that the boy’s dad was abusive, but there was no follow-up.

Later, the boy stayed at a home where a woman was on probation for a firearms-related offence, but the local child and family services agency approved of the living arrangement anyway.

“It came back as high risk and they did not appear to do anything to follow up to mitigate that risk,” Penrose said.

At 16, the boy was couch-surfing and was at one point placed overnight in an acute mental-health facility for his suicidal thoughts. He checked out the next day and there was limited assessment of his condition, Penrose said.

Shortly before his 18th birthday, the boy died in a single-vehicle rollover. He had been drinking and was not wearing a seatbelt.

Penrose’s call for better training of social workers echo concerns raised at a public inquiry into the death of Phoenix Sinclair in 2005. The girl was beaten to death by her mother and mother’s boyfriend after she repeatedly fell through the cracks of the child-welfare system.

Social workers often lost track of Phoenix, closed her file without seeing her, and were unaware that her mother’s boyfriend had a long history of domestic violence.

Friday’s report is a first for Penrose. Until recently, she was not allowed to publicly release her investigations into individual cases. She was also recently given expanded powers to look beyond child welfare and examine schools, the justice system and other areas.

In the coming months, Penrose hopes to complete her investigation into the case of Tina Fontaine, a 15-year-old girl whose body was pulled from the Red River in 2014. Tina had walked away from a hotel where social workers had placed her. The man charged in her death, Raymond Cormier, was found not guilty earlier this year.