MONTREAL — A seven-year-old girl from Granby, Que., whose death in 2019 galvanized the province into reforming the youth protection system, was failed by both individuals and institutions, a coroner said Wednesday.
Institutions that were supposed to protect the girl — including youth protection services, the health network and the school system — did not co-ordinate a proper response to save her, Géhane Kamel says in her report released Wednesday into the death of the child.
"I don't want to say that everyone threw in the towel because there are people who, during the course of this child's life, had tried to raise flags but were not heard," Kamel told a news conference.
The girl's killing from asphyxiation in 2019 led to a high-profile public inquiry and triggered reforms to the youth protection system. On April 29, 2019, she was found in her home in Quebec's Eastern Townships in cardiorespiratory arrest with adhesive tape covering part of her body, including her mouth, and died a day later in hospital.
Among Kamel's dozen recommendations is the need to improve communication between government departments, and to put children at the centre of all decisions in the youth protection system.
Her 26-page report highlights profound systemic failures, including a lack of communication between various institutions, and mechanisms that were not triggered for "a concerted response to prevent her death." The regional health authority found similar issues during its own probe.
"Everyone learned lessons from that," Kamel said. "But it's one thing to learn lessons, it's another to ensure it doesn't happen again."
Kamel's report included the girl's first name. A publication ban prevents media from using it, but she explained that if her report was the last public thing written about the girl, it should have her name included.
The coroner said all public officials, like doctors and school staff, share blame, not just youth protection officials. She noted protection agency staff cannot be the only people responsible for the well-being of children.
The young girl had been known to youth protection since birth and spent the first three years of her life with grandparents. Despite multiple calls about her to child protection for abuse and neglect, many of the calls were deemed unfounded.
There was a succession of case workers in her file, which was difficult for a girl who was diagnosed with attachment disorder. Although seven years old, she had the physical appearance of a four-year-old and was described in her case file as emaciated.
Police intervened 24 times at her home between 2012 and her death.
The day before she died, the girl had repeatedly tried to escape her bedroom, leading to her father and stepmother restraining her with adhesive table. The stepmother told the father the next day she had taped her "from head to toe" because she was screaming and trying to escape.
Kamel noted the only normal life the girl had was when she was with her grandparents. Her grandmother, who had custody before the courts forced her to give the child back to her father, agreed with the coroner's conclusions.
"Everyone truly let the little girl down, including the doctors, the school, the school board, and the DPJ (youth protection)," she told reporters. "Everyone has blood on their hands. What happened is unacceptable, and it must not happen again."
The child's stepmother was convicted of second-degree murder and unlawful confinement in the girl's death, and sentenced to life imprisonment without the possibility of parole for 13 years. In March 2025, the sentence was affirmed on appeal.
The girl's father was sentenced to four years in prison in January 2022 after pleading guilty to a reduced charge of unlawful confinement. He was granted parole last year.
The young girl's death led to a public inquiry that looked broadly at the youth protection system. A number of legislative changes followed the inquiry's final report, including the creation of a national director for the protection of children.
Social Services Minister Lionel Carmant told reporters in Quebec City that he would fulfil the coroner's recommendations, adding his government had made a number of changes since the tragedy.
Kamel noted in her report that despite investments, the backlog at the youth protection office in the Eastern Townships region persists. In 2024, there were some 650 files awaiting assessment, not far from the 785 at the time of the girl's death.
Lesley Hill, the province's national director of youth protection, says the child welfare system is committed to ensuring such a tragedy doesn't happen again.
"Since the terrible death … we have been redoubling our efforts to constantly improve the protection of children," Hill said in a statement. "Several professionals gravitated around this little girl and her family, and yet, we collectively failed in our task to protect her from abuse."
Kamel ended her report with a powerful message to the young girl in the form of a personalized letter in which she hopes the child has found peace and that her story isn't forgotten.
"Your name … resonates as a call to never again look away," the coroner wrote.
"You are the breath that pushes us to change, to build a world where every child is seen, heard, respected, and loved."
This report by The Canadian Press was first published Sept. 3, 2025.
— with files from Pierre Saint-Arnaud in Montreal.
Sidhartha Banerjee, The Canadian Press
