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In a damning investigation into the death of Métis teen Alex Gervais, British Columbia's new children's representative found serious mistakes by the provincial children's ministry, including its failure to try to find a permanent home for Mr. Gervais, even though he had family members who were willing to care for him.

Instead, a caregiver was paid more than $8,000 a month to look after the teen, but the report found that care amounted to checking in via text message. The caregiver was completely absent in the 10 days before the boy leaped to his death from the fourth-floor window of the budget hotel where he'd been placed, the investigation found.

The report – the first released since Bernard Richard took on the high-profile post last year – echoed some of the themes of Paige's Story, a 2015 report by Mr. Richard's predecessor that slammed the government for its role in the overdose death of a 19-year-old girl. The new report prompted the minister responsible to acknowledge Monday that the way the government contracts out services for children in care requires a complete overhaul.

The report also raises questions related to the province's long-standing shift of some child welfare responsibilities to delegated aboriginal agencies, one of which was charged with caring for Mr. Gervais when he died in September, 2015.

"I think the entire system failed," First Nations Summit spokeswoman Cheryl Casimer said Monday.

"In this instance, there were a lot of errors made on behalf of the agency – so in my opinion, there needs to be more accountability and transparency," she added.

But Ms. Casimer also defended delegated agencies, saying the groups are caught between trying to comply with provincial standards and guidelines and providing culturally appropriate care, often with tight funding and overloaded staff.

Mr. Richard's report, titled Broken Promises, outlines the life of the Métis youth, who was born into trying circumstances and "left to drift" through the care of the provincial Ministry of Children and Family Development (MCFD). In his 18 years, Mr. Gervais lived in 17 different placements under the watch of 23 different social workers and caregivers.

"At the very end, Alex was alone," Mr. Richard wrote.

After Mr. Gervais's residential home was closed and he was placed into the hotel, a delegated aboriginal agency paid a former respite caregiver more than $8,000 a month to care for him, as well as costs to live in an adjoining room to Mr. Gervais's room at the hotel.

The report does not identify the delegated agency, but The Globe and Mail previously confirmed it was the Fraser Valley Aboriginal Children and Family Services Agency.

On Monday, that agency referred media calls to the ministry.

According to Mr. Richard's report, the caregiver was rarely on-site and Mr. Gervais's care was left largely to his girlfriend.

In the weeks leading up to Mr. Gervais's death, the teenager and his friends told the caregiver that he was suicidal. This information was never passed on to his social worker.

The caregiver was also completely absent in the 10 days before Mr. Gervais's death. During this period, Mr. Gervais texted a former caregiver to complain about his current caregiver, accusing his current caregiver of neglecting him and pocketing money allocated for his care.

"There seemed to be no plan whatsoever for Alex other than to age out," said Allen Hoolaeff, a former caregiver who lived with Mr. Gervais in three different residences over a seven-year period. (In British Columbia, children "age out" of government care when they turn 19.)

Mr. Hoolaeff said he quit his job before Mr. Gervais's home was closed but kept in touch, including through text messages – which Mr. Hoolaeff said he provided to investigators and were excerpted in the report.

On Monday, MCFD Minister Stephanie Cadieux said the ministry accepts responsibility for what happened to Mr. Gervais and is working to make changes.

"There is no argument with the facts in this report," Ms. Cadieux said. "If I had written this report, it would say the same things."

Planned changes include enhancing the ministry's computer system to automatically alert the provincial director of child welfare if a child is bouncing between foster or group homes; taking responsibility back from contracted agencies for criminal background checks for residential caregivers; and making sure "each and every one of the more than 7,000 kids in ministry care must have a care plan in place," Ms. Cadieux said.

The ministry will co-operate with the Auditor-General, who plans to audit the ministry's oversight of contracted services for at-risk children and youth.

Asked about Mr. Gervais's final caregiver, Ms. Cadieux acknowledged that such subcontracting was "just not appropriate."

"Clearly, our contracting needs a complete overhaul," Ms. Cadieux said.

"We bring all of it back to Victoria for oversight so that we can standardize what we are doing and have better oversight in the long run with an ultimate goal of having less of this contracting altogether." The caregiver in question is no longer providing care to children, but Ms. Cadieux said she does not know whether he will face any sort of discipline.

Monday's report also identified a lack of permanency planning that led to "profound instability and neglect" in the boy's life. While his biological parents could not care for him, Mr. Gervais's stepmother had a deep affection for him, expressed a desire to take him in and was characterized by social workers as stable and dependable.

However, the ministry ultimately chose to place Mr. Gervais in another foster home, due in part to the stepmother's tumultuous relationship with Mr. Gervais's father, and in part because MCFD supervisors saw the stepmother's repeated requests for more support as unreasonably demanding, the report stated.

When Mr. Gervais was placed with her briefly in the fall of 2006, she received just $700 a month in support from the MCFD – a fraction of the $4,600 per month his previous foster placement had cost, and the $8,000 per month the final caregiver would later receive.

Mr. Gervais referred to his stepmother as "mom." He was often upbeat and happy after a visit with her, and once described their separation as "having [my] heart torn in half," the report stated.

British Columbia NDP Leader John Horgan said the stark difference in support payments to the stepmother and the caregiver are indicative of a broken system.

"$700 versus [$8,000], a family that wants to help a young man get his life back together and someone who's getting paid to text periodically," Mr. Horgan said. "I just don't know how anyone can read this report and not see a system that is broken and a government, quite honestly, that just doesn't care."

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