The coroner in the inquest into the death of a six-year-old boy who was killed by an older child on a Saskatchewan reserve says there were two victims.
"One deceased and one with some grave problems," Alma Wiebe said Friday.
She spoke Friday afternoon after a jury tasked with finding ways to prevent a similar death released 19 recommendations.
Lee Bonneau was found with head injuries in a wooded area on the Kahkewistahaw reserve in 2013. He had last been seen walking with an older boy outside a recreation complex while his foster mother was playing bingo.
Saskatchewan's children's advocate determined the 10-year-old boy, whose name is under a publication ban, had behavioural issues and probably should not have been in the community unsupervised. Because he was under 12, he could not be charged under the Youth Criminal Justice Act.
Ms. Wiebe said the jury picked up on the fact there were failures in the system and both children had fallen through the cracks to some extent. "I thought their recommendations were thoughtful, they were based on the evidence," she said.
The recommendations were mainly directed toward the Ministry of Social Services and the Yorkton Tribal Council Child and Family Services. They ranged from improving mental health supports to funding a facility for children under 12 who have complex needs.
"Through the evidence these last two weeks, it was loud and clear that some children are better served in this province than others," Ms. Wiebe said.
Recommendations also included improving communication between agencies and revising the size of service centres for rural offices.
The jury also recommended that fetal alcohol syndrome, attention deficit hyperactivity disorder and mental health issues should be addressed as soon as they are identified in children.
The inquest heard from 27 witnesses over two weeks.
"It was very emotional," Ms. Wiebe said. "It's heartbreaking for anyone to hear that kind of evidence. There were a lot of tears in the court room."
Cpl. Donna Zawislak, who was the lead RCMP investigator on the case, had testified that the 10-year-old boy had been known to police and was the subject of complaints including inappropriate sexual behaviour, animal cruelty and break and enters.
The inquest also heard that the boy had been hearing voices.
Sheri Woods, the lawyer representing the boy, said on Friday that she was satisfied with the recommendations.
She said the jury considered the fact that the system "failed two families."
Ms. Woods said her client is "receiving the care and the treatment that he likely should have received a very long time ago and he's doing well."
Tammy Kirkland, a spokeswoman for the Ministry of Social Services, said the case is "deeply tragic."
"We're in a much better place today to respond to the needs of children and families because of accountability measures like this," she said.
She added the ministry will review the recommendations before it provides a formal response.
Joanne Moser, the lawyer representing the Yorkton Tribal Council Child and Family Services, said the recommendations that recognized a need for more funding for the agency were particularly helpful.
"There are so many children that have special needs," she said.