WARNING: This story contains graphic details.

B.C.'s watchdog for children and youth is calling for a formalized action plan amid a new report detailing the horrific case of a 11-year-old Indigenous boy who died while in foster care.

On Tuesday (July 16), a report from the Office of the Representative for Children and Youth, titled "Don't Look Away," described 'Colby' just like so many other 11-year-old boys.

He loved to play soccer. He read Archie comics. He got along with everyone at school. He was particularly interested in science and math. He was a great brother, who when his sister was sad would lace his fingers through hers to comfort her.

"That was one of the most beautiful things that we learned about Colby was his generous heart and spirit," children and youth representative Jennifer Charlesworth told media during an event at the Vancouver Convention Centre to release the report. 

The report details findings into Colby's death in the Fraser Valley in 2021, as well as the stories of 14 other children who were subjected to harm that either caused life-altering injuries or death, all while in foster care or the child welfare system. 

Colby is the pseudonym the Representative for Children and Youth is using for the child. The report does not identify this case beyond the region of the Fraser Valley, however, a man and woman accused of inflicting horrible abuse on two foster children were sentenced to 10 years for manslaughter and six years for aggravated assault. The case sparked calls for action from various Indigenous leaders and an i. 

The documented abuses took place between December 2020 and February 2021, according to the court, detailed in 400 hours of footage from 16,000 video clips from four closed-circuit cameras in the home. The children were forced to eat feces and vomit and drink urine. 

"He should have been able to be happy and carefree. Instead, he became the centre of headlines, homicide detectives had meetings and there were debates in the legistlature."

On Tuesday, the child and youth watchdog said that "it doesn't matter" to name those involved in order to move forward. 

The 196-page report detailed Colby's life, from complications at his birth to his life with his four other siblings and, ultimately, the events leading to his death. 

Colby was born in the summer of 2009, through an emergency C-section. He was born with a genetic disorder that resulted in skeletal abnormalities, respiratory challenges, a cardiac condition and renal disease. He also required heart surgery in both 2018 and 2019.

Charlesworth said there can be fears and anxiety about contacting the Ministry of Children and Family Development, but starting a connection in the early years for a family more at-risk is important to build a relationship "long before there's a crisis."

"For Colby's family, when he was being brought home from the hospital, after being born with very significant medical complexities, that was the time you'd have public health nurses, you'd have a nurse navigator, you'd have other people that are not part of the protection service system that starts to wrap around that family."

Colby's mother, Violet, was determined to provide a more stable life for her children than she had experienced growing up. The report details that Violet's mother struggled with substance use, Violet had to help care for her siblings and she reported being raped, but was told to not report it. 

At 20, Violet had her first child with a man, Colton, who was six years older than her. 

"As their relationship grew in love for one another, it also developed a dark side, marked by poverty, instances of violence by both partners, housing insecurity and substance abuse as well as involvement with both police and the child protection system," the report states. 

An incident in 2007 brought Violet to the attention of the Ministry of Children and Family Development for the first time. Colby was born less than three years later.

After several moves 鈥� including a ministry decision to place Colby and two of his siblings in the care of his maternal grandmother 鈥� Colby and his elder sister were placed in the care of Violet's cousin, Staci, despite a great-aunt and great-uncle and his paternal grandmother being options.

The report calls it a "fateful placement." It adds that a simple search would have revealed that Staci had several substantiated child protection concerns, there were allegations of intimate partner violence by her partner, Graham, against her and sexual violence allegations against Graham. 

The COVID-19 pandemic hit, and other cracks began to show. Emails to the ministry from Staci said she was "overwhelmed" from caring for and homeschooling six children. She would sometimes keep them home from school.

The report notes that in the last seven months of Colby's life, Staci withdrew him and his sister from all contact with family members and professionals outside of their home. It adds that the pandemic allowed the isolation to go unquestioned. 

Colby's dad saw him one last time, in December 2019, just two months into the stay with Staci.

鈥淲hen I saw him last has been haunting me a bit,鈥� Colton is quoted in the report. 鈥淚 dropped him off at that house, he just latched onto me, grabbed me and squeezed me. I took it as he鈥檚 going to miss me."

The report added that Colby missed 21 days of school in a 26-day period. Teachers and staff tried to contact Staci and find accommodations, but she said she wasn't interested in the options.

Charlesworth said that right now an educator or medical professional might not contact the ministry and incidences are judged as if it's an isolated event. 

"What we're saying is that all of these pieces of information start to illustrate a pattern for a family, and when you start to see things in conjunction with one another, you begin to get a sense of what's really going on with that family.

As part of her recommendations, Charlesworth said there needs to be a whole-system approach, rather than just centering on the Ministry of Children and Family Development.

"It would be much more about the early the early supports and saying, 'Mama, what do you need in order to be able to support your child right now? I'm concerned about the violence that you're experiencing. Is there a way that we can help you and what might be helpful in order for you to be able to keep yourself and your children safe?'"

Violet died 20 months after the death of her son in what was believed to be a toxic drug poisoning.

Children and Family Development Minister Grace Lore said that on behalf of the provincial government, she apologized.

"It is clear, Colby and his family were failed."

Following the recommendations, Lore's ministry said the province plans to develop a cross-ministry group of senior public officials. It will include helping to to develop a child and youth action plan that focuses on wellbeing, strengthening communication between ministries and exploring the reconfiguration of child and family services across ministries.