After nine hours of deliberation, a five-woman coroner's jury in the inquest into the death of three-year-old Savannah Brianna Marie Hall found that the child's death was homicide by suffocation.
Corinna Hall, the girl's natural mother, wept tears of joy Saturday as she hugged her lawyer, Peter Grant, outside the courtroom just after the jury's verdict was released.
"This has been a most effective inquest," Mr. Grant said during a media conference in front of the courthouse. Seventeen of the jury's 26 recommendations were directed to the Ministry of Children and Family Development, and they call for big changes in how the ministry operates, he said.
The verdict and recommendations are certain to come up for serious discussion in the B.C. Legislature, Mr. Grant said.
Brian Gilson, lawyer for foster mother Patricia Keene, said he could not comment on the jury's findings and recommendations until he had spoken to his client.
About 15 minutes before the courtroom was reopened for the coroner to receive the jury's verdict, about 20 members of the Lake Babine Nation held a candlelight vigil in front of the courthouse in Savannah's memory.
The jury determined that the immediate cause of Savannah's death was "hypoxic ischemic brain injury" (damage to the brain caused by lack of oxygen in the blood flow into that organ). They also determined the antecedent (preceding) cause of death was cerebral edema (brain swelling) due to or as a consequence of suffocation.
Savannah died Jan. 26, 2001, in Vancouver around 5:50 p.m., the jury determined.
Savannah was found unresponsive in her foster-care home in Prince George on Jan. 24, 2001, and died in B.C. Children's Hospital two days later. Two weeks of testimony in the coroner's inquest concluded Friday evening. Coroner Scott Fleming began delivering his charge to the jury Friday night, and concluded his charge just before noon Saturday.
A coroner's jury does not find criminal responsibility. A finding of homicide in the context of a coroner's inquest means that, whatever the context, some intentional action by someone caused a death.
The jury's first 17 recommendations, all addressed to the minister of children and family development, included calls upon the ministry to make several changes including:
Improve their procedures relating to the recording and sharing of all information relating to both substantiated and unsubstantiated allegations that may relate to the safety and welfare of children in care;
Develop and implement a single document, equivalent to the "Child Services Case Snapshot," which records all allegations against a foster home;
Require that foster parents be trained in First Aid and CPR (cardio-pulmonary resuscitation);
Revise and clarify the Standards for Foster Homes as it relates to the use of both mechanical and physical restraints. These standards should specifically require the approval of a physician prior to their non-emergent use;
Revise the Supervised Visit and Transportation Record so as to require the signature of the visiting natural parent, and that a copy of the record be provided to the natural parent;
Require immediate notification to the applicable police agency of all serious incidents involving physical injury to children in care.