An inquest into the death of a woman with Down syndrome who died while living in a caretaker’s home has concluded her death was a homicide, and that she died of starvation and malnutrition.
The inquest has heard that Girard was found dead in Astrid Dahl’s Port Coquitlam home in October 2018. She weighed just 50.6 pounds when she died and lost about 50 pounds in the three months before she died, the inquest heard.
The 54-year-old with Down syndrome had lived under a residential home-sharing agreement with Dahl for about eight years, an arrangement overseen by Kinsight Community Society, a non-profit contracted by Crown corporation Community Living B.C.
Dahl was subsequently convicted of failing to provide the necessaries of life in Girard’s death.
More oversight, more funding recommended
Coroner’s inquests are fact-finding exercises and do not assess fault. However, they are empowered to make recommendations aimed at preventing similar deaths in the future.
On Friday, a five-member coroner’s jury delivered 13 recommendations — 11 of them for Community Living B.C.
“With 13 recommendations, they have a starting point,” Girard’s sister Sharon Bursey said.
“They need to change a lot. Funding, benefits, medical health for the individuals. Complex needs — they need to understand what they are.”
The jury’s top recommendation called on CLBC to develop a case management system to provide oversight on the medical quality of life for everyone in its care.
It also called for financial support to ensure family members can care for their loved ones in the same way a home-share provider does if they choose, and to “immediately” and annually boost the financial support home-share care providers and coordinators get.
The jury further recommended increased funding to contract home-share coordinator agencies to reduce the number of patients under one coordinator’s care, and to ensure coordinating agencies assess the capacity of people in their care and have power of attorney where necessary.
CLBC should also perform random, risk-based assessments and well-being check-ins at home-shares, and provide ongoing paid training for home-share providers, the jury said.
The jury made two recommendations to the Ministry of Health and the Ministry of Social Development and Poverty Reduction.
It called for the province to immediately reinstate a medical consultant position at CLBC, and to immediately reduce wait times for clients to access health care plans.
Inquest testimony
The inquest heard from 18 witnesses, including B.C.’s advocate for service quality who said home-share providers are facing exhaustion, burnout and are constantly in “crisis mode.”
Cary Chiu testified people offering care in their homes for people with developmental disabilities need to be paid more to ensure the integrity of the program and revitalize the quality of its pool of providers.
Dahl told the inquest she received around $2,000 a month from the home-share program to care for Girard as well as some money to pay for respite if she needed help.
Dahl testified to being in “denial” about Girard’s condition, telling the inquest when the woman began losing weight she thought she would bounce back if she could take care of her.
She further testified that Girard hated going to the doctor and dentist, and would have a “meltdown” ahead of appointments. Girard, she said, had the right to refuse to go.
She said she told Kinsight about what was going on but she was doing what she thought was best for Girard.
“Now, I wish I could go back in time and do it differently,” Dahl testified.
“I was stuck in a loop of not knowing what to do. No one else offered to help me find a solution.”
The inquest heard that Girard hadn’t seen a doctor for four years before she died.
Community Living B.C. manager Lisa Evans told the inquest all of its clients should be seeing a doctor annually.
But the inquest heard the agency does not have the ability to check whether its clients had actually had those visits.
The inquest also heard B.C.’s auditor general had reviewed CLBC in 2021, authoring a scathing report about gaps at the agency.
The province’s assistant deputy minister of social development and poverty management acknowledged “significant gaps” in CLBC’s oversight framework, but said “many” of them had been addressed.
Girard’s sister Sharon Bursey has said she wants a full audit of CLBC and Kinsight.
