'A situation of chronic neglect:' Ombudsman releases scathing report after boy found malnourished and living in squalor (CP24)

December 20, 2022

20 December 2022

A 10-year-old boy was found malnourished and living in squalor in October 2018 but the Children’s Aid Society of Toronto refused to take him into their custody, prompting “horrified” police officers to step in.

Chris Fox
This link opens in a new tabCP24
December 20, 2022

A 10-year-old boy was found malnourished and living in squalor in October 2018 but the Children’s Aid Society of Toronto refused to take him into their custody, prompting “horrified” police officers to step in.

This according to a newly released report from Ontario’s Ombudsman which reveals a series of repeated failures by CAS Toronto to protect the boy after he was placed in the care of his great-uncle.

In the report, titled ‘A Voice Unheard: Brandon’s Story,’ Ombudsman Paul Dubé concludes that CAS Toronto’s response to concerns about the child’s welfare was “marred by a series of delayed investigations, safety assessments, visits, supervision sessions, and service plans.”

Dubé also says that CAS Toronto erred by “routinely” failing to meet with the boy in private, “leaving his voice unheard and ignored.”

“The CAS’s response to the child protection concerns raised in Brandon’s case were often untimely and inadequate. Rather than proper diligence, its actions were characterized by delays and deficiencies,” Dubé notes in the report.

Dubé’s 90-page report covers the period from December 30, 2015 to October 26, 2018 when “Brandon,” a pseudonym used to protect the boy’s identity, was between the ages of seven and 10.

The report reveals that CAS Toronto received multiple reports from school officials raising concerns about Brandon’s care but permitted him “to live in chronically neglectful conditions” over a period of years.

The situation ultimately came to a head on October 22, 2018 when a CAS worker decided to visit the boy’s home with police after his great-uncle failed to show up for a scheduled meeting at the school.

In his report, Dubé says that the case worker arrived to find Brandon “curled up on a stained futon in the main living area” in what they later described as a “catatonic state.”

He was taken to hospital, where doctors determined that he was 15 pounds underweight for his age and height, had an enlarged kidney and was suffering from a kidney infection.

Dubé says that the case worker believed that Brandon was “at immediate risk of harm” and called a supervisor to ask for permission to formally apprehend him but had the request denied, prompting police to intervene and formally apprehend the boy themselves.

“The police officers were horrified by Brandon’s living conditions, including the permeating stench from cigarettes and cat litter, the filthy state of the floors and walls, the urine-streaked futon without sheets where Brandon lay wrapped in a dirty blanket, and the live and dead cockroaches littering the floor,” Dubé wrote in the report. “The police officers assumed that the CAS would remove Brandon from the home for his own safety. After they learned the CAS had no intention of doing so, the Toronto Police Service formally apprehended him, and he was taken to a foster home.”



Dubé pointed out in his report that Brandon was “not the victim of deliberate abuse” and appeared to have a close relationship with his great-uncle.

But he said that the great-uncle’s capacity to care for him became “severely compromised” over time.

During this period there were several red flags that Dubé argued should have prompted a more fulsome response by CAS Toronto.

In one example, detailed in the report, Dubé said that a vice-principal notified the agency about an “incident of suicidal ideation” involving Brandon in April 2017. However, he said that there was “no record of any follow-up with the family or attempt to interview Brandon” about the incident.

Dubé said that a CAS case worker was also contacted by Brandon’s pediatrician about a month later and informed that the boy had “kidney damage and was in urgent need of mental health support.” The pediatrician raised concerns at that time that the boy’s great-uncle appeared to be “slurring his words” but Dubé said that “it does not appear that there was any substantive follow-up” to the allegations.

“Brandon’s situation degraded over time to the point of crisis,” Dubé said. “Unfortunately, during the period in question, the CAS was distracted by the assurances of Brandon’s family. It lost sight of its responsibility to act in his best interests, leaving him to suffer in silence in a situation of chronic neglect.”



Dubé said in the report that “more credence” should have been given to “those who had witnessed Brandon’s physical state, behaviour and living conditions” following the visit to his home on Oct. 22, 2018.

He said that instead the “CAS placed significant emphasis on the existing supervision order” and initially argued that Brandon should have been returned to the care of his great-uncle.

Dubé said that while the standard in child protection needs to be “the best interests of the child” rather than “trying their best,” that distinction “appears to have been lost at times in Brandon’s case.”

“The CAS should use Brandon’s case as an example for supervisors, to encourage them to carefully consider the opinions of workers and other professionals in the field when assessing immediate risks of harm and a child’s best interests,” Dubé writes.

Dubé makes a total of 18 recommendations in his report.

CAS Toronto has agreed to implement all 18 recommendations and in a news release Dubé said that he has been “encouraged” by their response so far, which has included a commitment to updating his office on their progress every six months.

In a statement provided to CP24.com, the agency said that its goal “is to deliver exceptional service to children and youth” but cannot do that “without critical feedback and effective accountability measures.”

“We accept all of the recommendations in the report and will continue to work closely with the Ombudsman’s office. Further, we would like to thank the Ombudsman staff for their work on this case and the recommendations they provided our agency,” the statement notes.