A coroner's inquest into the death of toddler Sherry Charlie recommended Friday night that Premier Gordon Campbell reinstate the children's commission his government cut in 2002.
The recommendation came at the end of a 10-day inquest in which the jury deliberated for 4½ hours and came back with 19 recommendations.
The recommendations were directed to the director of the Child Family and Community Services Act, governing child protection in British Columbia, the RCMP, the B.C. Coroner's Service and West Coast General Hospital in Port Alberni.
The recommendations were also directed at Usma, the aboriginal child welfare agency, and the Nuu-Chah-Nulth Tribal Council.
Sherry was 19 months old when an uncle, Ryan Dexter George, beat her to death on Sept. 4, 2002.
She was placed in George's home by Usma, the Port Alberni area aboriginal child welfare agency that was working with the provincial Children and Family Development Ministry.
Sherry's death has been the focus of intense political scrutiny since last July when the B.C. Liberal government released a long-awaited review of the case that cited poor communication and lax procedures between child welfare agencies.
The review concluded Sherry was placed in the home even though the government's children's ministry and Usma had yet to complete all the proper criminal and family checks on the George home.
It sparked at least six other reviews of the handling of Sherry's case, including an independent probe of child protection in the province by Ted Hughes, a former judge and B.C. conflict-of-interest commissioner.
Mr. Campbell said last November he must take the blame for what he called the systemic breakdown of the government's plan to review child deaths, including Sherry's.
Solicitor General John Les said budget cuts and government-wide incompetence resulted in his government's failure to properly review the deaths of 713 children.
The files were shipped to a Victoria warehouse where they sat unattended for three years, he said.
The Opposition New Democrats have consistently said the government must reinstate the former position of the independent children's commissioner, whose mandate included reviewing and reporting on deaths and injuries of children.
The Liberals cut the children's commissioner in 2002, citing a review that found too much duplication between the office, the B.C. Coroner's Service, the child and youth advocate and the ombudsman.
The inquest jury recommended that all social workers have access to the same training regardless of whether they are an agency, such as Usma, or a government social worker.
The jury recommended the government's Kith and Kin program, which was used to place Sherry in the home where she died, ensure that criminal record checks, family history checks and reference letters must be completed before the child moves to the home.
It recommended future Kith and Kin child placements require three letters of reference, one each from the paternal and maternal sides of the family and one from a neutral person who knows the potential caregivers.
The jury recommended to the RCMP that the officer investigating any child death should attend the autopsy so there is direct discussion regarding findings and their significance.
Coroner Liana Wright said the inquest has been a difficult two weeks for everyone.
"Nothing can be more devastating than the loss of a child," she said.
"I hope that these proceedings can contribute in some way to the healing that must begin."
Francis Frank, the tribal council president, said he will discuss the jury's children's commission recommendation when he meets next week with Children's Minister Stan Hagen.
"We wholeheartedly support that and I will be raising that with minister Hagen in my meeting next week as well as communicating and corresponding with the premier," he said.
Lawyer Lex Reynolds, who represented Sherry's paternal grandparents at the inquest, said the jury made a recommendation that ensures B.C.'s children are a priority.
"I'm pleased they recognized the importance of an independent agency that values children," he said.
The emotional inquest, which was expected to last one week and went twice as long, ended its testimony earlier in the day with Sherry Charlie's grandmother.
April Frank broke down in tears as she told the inquest she has been living with the guilt of trusting the girl's uncle with her care before he beat the toddler to death.
"I trusted and I was assured the trust by Ryan George," said Ms. Frank.
"I've had many sleepless nights for 3½ years. I'm sorry for the decision I made."
Simon Lucas, a well-known hereditary chief and Sherry's great-grandfather, said outside of the inquest he visited George in jail and forgave him for beating his granddaughter to death in an attempt to lift the burden from his family.
"He looked at me and said the only thing I can say is 'I'm sorry,'" said Mr. Lucas.
Mr. George, 34, pleaded guilty to manslaughter, admitting he beat and kicked Sherry to death because she wouldn't stop crying. She had been in his home 22 days.
He originally said Sherry died when her older brother Jamie, who was 3½ years old, pushed her down the stairs.
The inquest heard that Sherry and Jamie were moved into home of Mr. George and the children's aunt, Claudette Lucas, by Usma.
The children were placed in the George home despite his extensive criminal record, which included four assault convictions - three of them spousal assaults - robbery with violence and arson. He was on probation for spousal assault when Sherry died.
Mr. George was sentenced to 10 years in prison for manslaughter in the child's death. He was brought to the inquest in shackles last week and testified he should never have been permitted to care for children.
On Friday, an official in the B.C. Children and Family Development Ministry said plans are being worked on to send more child workers into the province's regions.
"We will ship staff to regions to ensure close contact with the (social and children's) agencies," said Julie Dawson, a director with the ministry's aboriginal department.
Sherry and Jamie were taken from Ms. Frank's daughter, Juliana, and her husband, Trevor Charlie, after complaints of alcohol abuse and neglect.
Ms. Frank said she wanted to take the children, but was finding it difficult because she was eight months pregnant and already caring for three other children of her own.
She said she wasn't aware of Mr. George's full criminal past, but when pressed by coroner's lawyer John Orr, she replied: "I do probably have knowledge of that."
Tensions at the inquest peaked Wednesday night when a sheriff's officer removed a man from the courthouse as he yelled, "Where's the truth?"
Usma social workers testified they used incomplete criminal and family history records when they decided to place Sherry and Jamie in the George home.
The social workers said they were aware of one spousal assault conviction, but not the other three assaults. They said they believed the assault was an isolated incident, because Claudette Lucas, who worked in the same building as they did, told the social workers her husband was turning his life around.
The social workers also testified they didn't have the full case history that B.C.'s Children and Family Development Ministry had on the Lucas and George home.
The history was 31 pages and included allegations of child abuse. One incident involved an alleged beating incident where one child left a bedroom with black eyes.
The case history also included allegations of a four-month-old baby being kicked.
Ms. Lucas testified at the inquest that one of the four children she and George had together died at four months old. An autopsy determined her cause of death was an intestinal problem, she said.
None of the allegations investigated by the children's ministry were substantiated or resulted in charges.