Signs Ontario girl needed help before she died were ignored by child protection workers: report

A new report obtained exclusively by CityNews on the death of four-year-old Keira Kagan examines how the system intended to protect her ultimately ignored the risks she faced.

Earlier this week, CityNews revealed that a report for the coroner concluded Keira was likely killed by her father, Robin Brown, in a murder-suicide three years ago. It also found her death was “predictable and preventable” based on the 22 risk factors her father displayed.

Ontario’s chief coroner has since announced an inquest into Keira’s death.

A second report, written by an expert reviewer as a part of the work of the Child and Youth Death Review and Analysis unit for the coroner, takes particular aim at Jewish Family and Child Services, the children’s aid agency overseeing the case.

“Child protection workers […] did have evidence of emotional harm, and little was done by way of supporting the child directly,” wrote expert reviewer Kim Snow, a specialist in child protection and children’s mental health at Toronto Metropolitan University.

“All the concerns I had for Keira’s emotional and physical well-being and I was completely ignored,” added Jennifer Kagan, Kiera’s mother.

Keira was known as a sensitive and precocious child; she was a big sister and a schoolmate. However, she was also in therapy. Snow noted that Keira required treatment for distress, and there was evidence of coercive control.

During the custody dispute that lasted most of Keira’s life, Jennifer Kagan warned the courts and children’s aid workers multiple times that Keira was in harm’s way when she was with her father.

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“The mental cruelty he exhibited and the coercive controlling behaviours, isolating her from friends and family … These are not normal things; to take a child for the weekend, cloister her in house, shutter the blinds,” said Kagan.

“I begged and pleaded with them … I told the case workers, ‘How much longer can this go on? How much longer can this child be put through this?'”

The report and Kagan noted there were times when Brown wouldn’t allow Keira to call her mother, despite a court order requiring contact during the father’s custody time.

“The child herself raised concerns with the child protection worker about not being able to contact her mother,” noted Snow in the report.

“She confided to the worker that she believed her father wanted to keep her to himself.”

Educators had also expressed apprehensions in at least two instances documented in the report, and Keira gave examples of “isolation” to her case worker.

Snow added that this impact on Keira and her emotional distress “needed to be assessed as a form of child abuse,” but it never was.

“Keira was seeing a private psychologist who wrote several reports expressing concerns … that was promptly ignored,” added Phillip Viater, Keira’s stepfather and a family law lawyer.

The report notes that the CAS exists to protect children, yet Snow found Keira was not protected.

“Notably absent in this case is the voice and perspective of the child. The child’s concerns do not seem to drive service, nor do they seem to be engaged in safety planning, which is surprising given that the mandate of the service is to protect the child.”

Keira described as child with aspirations “of changing the world”

Days before Keira’s death, a judge asked for a risk assessment as Brown’s concerning behaviour escalated.

Shortly after, on a Friday, Keira’s mother said the Jewish Family and Child Services case worker called and told her Brown was exhibiting the behaviour of a person who could harm or kill their child. The agency decided to wait until Monday to address it. On Sunday, Brown and Keira fell to their deaths from a cliff in Milton.

The report describes Keira as a child with “aspirations of changing the world.” Her mother is determined she still will.

Kagan has drafted Keira’s Law. If passed by the federal government, it would require judges to have regular training on domestic violence and coercive control. It’s close to becoming law as the Senate’s legal committee has recommended it move forward.

RELATED: Keira’s story: How a broken system left a little girl dead

“We could not allow what happened to Keira to be buried. You can’t just have things shoved under the rug when that’s your child and your child’s life. That’s an insult to the child,” shared Kagan.

Kagan’s advocacy has come at a cost, she is constantly reliving her child’s death, but she said she wouldn’t stop until she knows she has made a change. “I can imagine her saying, ‘Mom, Phil, you got this. Keep going, keep trying to fight for other children.'”

Kagan is also suing Jewish Child and Family Service. It has declined CityNews’s request for comment.

One of the many recommendations in Snow’s report is that a child in Keira’s situation should have their lawyer solely look out for their interests.

Many of the failures of the court and child protection systems have been identified before, and recommendations made. It will all be scrutinized in the coroner’s inquest, expected to begin in 2025. As time passes, Keira will forever be four years old, a bright and sassy child in her family’s memories.

“For us, it’s like yesterday, it’s today, it’s not three years for us,” said Viater. “It’s the same day; Keira is frozen in time, other kids are getting older, we live it, we live all of it.”

With files from Meredith Bond and Jessica Bruno