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A 12-year-old Indigenous boy with autism who was taken into foster care in 2016 after being found naked, starved and screaming was the subject of eight separate reports to child protection authorities, but no social worker had ever met with him, British Columbia’s children’s representative has found.

Jennifer Charlesworth said social workers failed to comply with basic standards when responding to reports about a boy with severe autism who she refers to as “Charlie.” She found that between 2006 and 2016, a range of professionals including police, doctors, income assistance workers and school staff contacted the provincial Ministry of Children and Family Development (MCFD) to report a child protection concern.

The report said social workers were told Charlie appeared malnourished, that there were concerns he wasn’t accessing adequate medical care, that he had stopped attending school and that his mother’s mental health appeared to be deteriorating.

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Katrine Conroy, the Minister of Children and Family Development, called the behaviour of the workers responsible for the case “inexcusable.”

Charlie was taken into provincial care on Jan. 20, 2016, after police came to his mother’s home. Officers found there were no adults present and he had been screaming for half an hour, according to the report.

“Charlie was found by police – naked and filthy, severely underweight, unable to walk, and living in a bedroom covered in garbage and feces,” the report said. Charlie’s mother, who was not Indigenous, was apprehended under the Mental Health Act on the same day Charlie was taken into care.

That was nine days after a social worker conducted a home visit in which she didn’t see him or his room, although Charlie was home at the time. The worker left without a plan to see him at a later date. The visit came 45 days after police notified MCFD they had responded to a call from Charlie’s mother saying she was hearing voices and being listened to through the vents in her stove.

Charlie is now thriving in specialized foster care and back in school, Ms. Charlesworth said.

Ms. Conroy said she is asking the provincial director of child welfare to further review the conduct of the staff involved.

“One of the most disturbing parts of the report was the admission by social workers they were unable to meet the most basic requirement of their job,” she said in a statement.

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But Ms. Charlesworth said the situation goes beyond individual workers. She said the fact no social worker ever saw or met Charlie is representative of systemic pressure social workers are under to do superficial and speedy investigations.

“Our observation here is that there has been a lot of pressure to assess the immediate need and move on and close the file,” she said.

In a statement released on Monday, the union representing social workers in the province echoed Ms. Charlesworth’s concerns.

“Chronic staffing shortages and workload pressures within MCFD and among front-line social workers have led to dysfunction in the care system for too long” said Stephanie Smith, president of B.C. Government and Service Employees' Union.

In her report, entitled “Alone and Afraid,” Ms. Charlesworth noted there were at least eight formal reports to the ministry.

“Despite four separate child protection assessments conducted by MCFD, no child protection social worker ever laid eyes on Charlie during a protection response until he was removed from his mother’s care,” the report says.

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The report found Charlie was not properly assessed or diagnosed until a hospital visit when he was six in 2009. At that point, a home visit was ordered, but the social worker spoke to his mother and didn’t meet with Charlie, who was still in the hospital. The file was closed.

But concerns continued. The report notes Charlie’s mother had not accessed funding and support available to parents of autistic children, that he had been completely withdrawn from school in 2011 and that no alternative education plan was in place.

The second home visit occurred after his mother called police in November, 2015, to complain she was being watched. The commissioner’s report said the child-protection worker on the case tried to contact the mother by phone between Nov. 24 and Dec. 16. She was not successful. The worker left for a two-week vacation and the file was not reassigned.

On Jan. 11, 2016, following another complaint, the worker again tried to contact Charlie’s mother. She was not successful, but visited the home anyway. In her case notes, she said the home was “clean and tidy” with no safety concerns observed. She did not meet Charlie because she was told he was sleeping.

But police went to the residence again after another complaint from a concerned citizen on Jan. 20. It was then that Charlie was taken into provincial care.

The report also noted that in 2008, Charlie’s mother had described her son as Indigenous to a service provider who then informed the child-protection worker involved with the family.

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Although the information was recorded in the social worker’s notes, it was not entered into the MCFD case management information system, as is required.

No one made further inquiries about Charlie’s culture or community. In fact, Charlie was not identified by ministry staff as being First Nations until after he was removed from his mother’s care in 2016, Ms. Charlesworth wrote.

She made several recommendations to the government, including that MCFD should “ensure social workers lay eyes on children and adhere to timelines during child protection responses” and “ensure identification and involvement of an Indigenous child’s family, community and culture is made at first point of contact.”

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