Background Content

Child Welfare (1-5)

Recommendations from Death of Tina Fontaine

March 12, 2019

A Place Where it Feels Like Home: The Story of Tina Fontaine (1999-2014)

This report is structured in two main parts. The first large part is the chronology of Tina’s life, which includes the time before she was born to the time after she died. This section, which is standard in all of our child death investigations, is an accurate and chronological summary that reflects countless sources of information. The chronology focuses on which public services were active during Tina’s life and we seek to identify where gaps in services existed or where there were opportunities for better interventions and supports. While not all systems within my scope were relevant to Tina’s story, the services my team and I are empowered to formally review include: child and family services, adoption, disabilities, education, youth justice, mental health, addictions, and victim supports.
The second large section of this report is focused on our analysis. In addition to the requirements laid out in my legislation, and based on the detailed and accurate chronology of events, we analyse the information and interactions to look for information such as:

  • What were Tina’s needs and those of her family?
  • What interventions and supports were offered and when?
  • What is the family perspective on the services they received?
  • What needs to be improved?
  • What do the experts say needs to happen?
  • What do the Elders say we need to remember?
  • What do youth say they need to feel supported? And,
  • How can tragedies like Tina’s death be prevented in the future?

The report concludes with 5 recommendations.