The head of a Crown corporation responsible for funding the care of a British Columbian woman with Down syndrome who died of starvation said the organization "failed her expectations" after an inquest jury ruled her death for homicide and calls for higher pay for family caregivers of adults with developmental disabilities. Disability.

It was one of 13 recommendations made by the coroner's inquest jury after hearing evidence about the 2018 death of Florence Girard at her carer's home. Florence Gillard lives with her carers as part of a government-funded project.

The head of a provincial Down syndrome advocacy group says detailed recommendations released Friday after nearly two days of deliberations show the need for a "complete reset" of the system.

Homicide verdicts are not a finding of criminal conduct, and inquest juries are not asked to find fault in the cases they hear but to make recommendations on how to prevent similar deaths in the future.

The jury foreman told coroner Donita Kuzma that in addition to being paid for basic necessities, home-sharing providers should also be paid a "living wage commensurate with the complexity of the care required".

Foreman said the jury heard "many times" that funding was insufficient to attract and retain home-sharing providers.

Girard died at the age of 54 and weighed only about 50 pounds.

She lived in Astrid Dahl's home for eight years as part of a home-sharing program funded by the provincial crown corporation Community Living BC, which is tasked with providing care to nearly 30,000 people with developmental disabilities in the province. Provide support to adults with disabilities.

"The system and CLBC have failed Florence," CLBC CEO Ross Chilton said in a statement.

"We have let down her family who believed Florence would receive the emotional and material support she needed," he said.

"The inspection at the time did not work. While it is painful to acknowledge the facts, it is important to do so so that we can prevent tragedies like this from happening in the future. On behalf of CLBC, my heart goes out to Florence's family, friends and loved ones."

Management and oversight of home-sharing programs across the province are outsourced to local organizations. In Girard's case, that's the Kinsight Community Association.

The jury heard that Gillard had not seen a doctor for four years before her death and that no one from the association responsible for her care had seen her personally in the months before her death.

Dahl told the jury that Gillard hated going to the doctor and would "break down" whenever the idea was discussed and said she didn't get enough support.

Dahl was convicted in 2022 of failing to provide Gillard with the necessaries of life.

Dahl told the jury she received about $2,000 a month to care for Girard, plus several hundred dollars for help when she needed respite.

Tiffany Wickham, the crown corporation's regional director, admitted funding for care staff "hasn't kept pace with inflation and housing costs".

Wickham told the jury the company "would not be able to maintain the service it provides" if wages were increased to account for inflation under the current budget.

Krista Maniezzo, who was the shared living coordinator at Kinsight Neighborhood Association at the time of Girard's death, testified that her workload with other paperwork led to Girard's case being ignored.

The inquiry heard there are about 200 home-sharing coordinators across the province, each responsible for managing the cases of 25 people.

The jury's recommendations to the Crown Corporation also included reducing the workload of coordinators and making their pay comparable to similar positions at the Department of Children and Family Development.

On the final day of testimony, Assistant Deputy Minister of Social Development and Poverty Reduction Adam McKinnon said the population of adults with developmental disabilities funded by Community Living BC is growing at about 5 per cent a year.

MacKinnon said the pay gap between coordinators and other similar positions was recognized during the last round of collective agreement negotiations.

"Instead of making it worse, we decided to intentionally maintain that disparity and not allow it to continue," he said.

"Then, over time, see how we respond to the challenges posed by the wage gap."

Other recommendations from the jury included moving away from a paper case tracking system to a more centralized system, conducting unannounced visits to families and providing "the same level of support as if the home was shared" for families who wish to keep their loved ones at home. Provider” (if they meet expectations).

Tamara Taggart, president of the Down Syndrome Society of British Columbia, both testified at the inquest and sat in on nearly two weeks of testimony.

In an interview after the recommendations were released, Taggart said she hopes government agencies asked to take action will listen to and respect them.

"They said loud and clear that the CLBC needs to be completely reset, and a lot of their recommendations were for immediate action. I think that says a lot as well," she said.

Taggart said her biggest takeaway from the investigation is the systemic failures that led to Gillard's death.

"What led to Florence's death was the systemic failure of Kinsight and the truly systemic indifference of the CLBC and the province. Its indifference to people with developmental and intellectual disabilities... We still have a lot of work to do."

A statement from the Crown corporation said it had significantly improved training, standards and policies for home sharing since Gillard's death.

Agencies contracted with home-sharing providers are now required to visit the homes at least every three months and are required to have a doctor visit once a year, the report said.

Since Gillard's death, $1.5 million has been spent to better monitor and track oversight systems within CLBC, and 12 new staff have been hired to strengthen oversight, the statement said.

The jury also recommended that the Ministry of Health and Social Development immediately reinstate the Crown Corporation's provincial medical adviser position, which was abolished in 2015.

Stephen Hall, BC Community Living's director of quality assurance, testified that the individual was employed by the Ministry of Health but worked with the Crown Corporation to perform tasks such as reviewing reports and assisting those accessing health-care-related services.

"If someone is hospitalized, we are planning to provide services and that doctor will be very helpful as well," Hall said.

This report by The Canadian Press was first published on January 24, 2025.

Ashley Joannou, The Canadian Press