An inquest into the death of a 14-year-old Saskatchewan boy in the custody of the social services ministry is revealing troubling gaps in the care provided to vulnerable youth.

Brandon Schafer Kovacs died of severe septic shock in Saskatoon’s Jim Pattison Children’s Hospital on Nov. 28, 2022. Now, a coroner’s inquest is detailing how he died, and what the people charged with his safe keeping observed in the days leading up to his hospitalization in the pediatric intensive care unit.

According to the director of programs for Saskatoon’s Eagle’s Nest facilities, Schafer Kovacs was pretty typical for the type of kids under their care.

But a number of factors were working against the teen that week, as a deadly coinfection of strep. pneumonia and influenza A took hold.

The jury heard about unclear policies, a complicated hierarchy of decision making and communication breakdowns at Eagle’s Nest Youth Ranch.

The house manager at his residence had only been in the position for two weeks, Eagle’s Nest was facing staff shortages due to illness and was pulling in workers from other residences, and the teen’s case worker – responsible for scheduling his appointments and immunizations and the primary contact with family – was an inexperienced undergraduate social work student.

Marie Digby, the case worker assigned to work with the 14-year-old at Eagle’s Nest, testified he had a pattern of embellishing illnesses to get out of school, implying staff were not inclined to take his medical complaints at face value.

On Monday, a staff member testified there was no functioning thermometer in the home the week before Schafer Kovacs’ death, and ultimately no staff member has testified to checking his temperature over the four days he complained of flu-like symptoms – and they were all asked.

Digby testified she knew that Schafer Kovacs’ illness was serious when she arrived at work on Nov. 25, five days after the teen initially asked to see a doctor.

“I put my bag in my office and went to check on Brandon,” she said, pausing to press a tissue to her cheeks, now reddened as tears began to flow.

“I went into his room and he was really disoriented and couldn’t speak. I ran downstairs and told Ryan [the house manager] we had to get him to the hospital. So, I got him into the truck and I drove as fast as I could to RUH.”

Once he was admitted, Digby said she first called Chantelle Schafer, the teen’s mom, then the ministry of social services to get a hold of his social worker – the person ultimately responsible for his care.

The jury heard Digby didn’t reach Schafer in a call, so she texted that he was in the PICU – the pediatric intensive care unit – and said he was warm and relaxed now.

It wasn’t clear Schafer knew what the PICU was at that time, and Digby did not specify her son was intubated, with a breathing tube working to push air into his weakened lungs.

On Monday, the jury heard Schafer Kovacs had a history of pneumonia prior to moving to the Eagle’s Nest, and had contracted it once before while living in the group home, although the illness was not disclosed to his mother.

The inquest heard Schafer Kovacs was brought into the care of the Ministry of Social Services under Section 9 of the Child and Family Services Act, where parents willingly give up some custodial responsibility to the state under a temporary agreement.

Given the shared duties at play, the lack of clarity in terms of each caregivers’ roles, and the precarious staffing situation at the care home at the time, the odds were not in Schafer Kovacs’ favour.

The inquest concludes on Wednesday with further testimony expected from Ministry of Social Services staff. Then, the jury of six civilians will be charged with making recommendations to prevent similar deaths in the future.