But the heart of the report is in the 34 pages which describe a teenage boy in desperate need of help, and a mother who cares deeply for her son but is at the end of her rope.
For more than two and a half years, son and mother bounced off the walls of the health care, social work, and justice systems.
A mountain of referrals, assessments, and reports were created, and a small chunk of that mountain of paperwork got completed.
Trouble starts in June 2009
The boy, called "John" in the report, came to the attention of authorities in June 2009, when he was 14. His mother called the RNC to report he had been beaten up, and police confirmed John had been a victim of bullying at his school.
John got into serious trouble in the following school year. He was caught using and selling drugs at school, skipping school, and he had increasingly serious conflicts with his mother over his behaviour.
His mother called Child, Youth and Family Services late in the fall of 2009, and started talking with social workers and police.
Behaviour gets worse
John was referred to youth mental health counselling in February 2010, but refused to take part. Health officials referred his mother to a parent support program and she talked of getting help for herself through her employee assistance program.
Meanwhile, John's behaviour got worse. He continued to skip school, use drugs, and he punched walls at home. John's mother's EAP counsellor told her John needed psychiatric help. John refused to get help.
John's mother told a social worker she was afraid that she could no longer keep her son safe. A social worker's jot notes from a telephone conversation with her said "not eating - very emotional - dying in front of me." "suicidal in Dec. - on Facebook".
More social worker jot notes indicated "Psychatrice [sic] problem." "Father used to do it - stories."
In June 2010, a note between a social worker and an RNC constable about John said in part, "It should be noted that there are concerns regarding [John's] mental health which are being explored at this time due to drug use and a strong family history of schizophrenia."
Teen abuses drugs, talks of suicide
Meanwhile, John continued to abuse drugs, stay out all night, get involved with fights, and talk of suicide.
In 2010 and 2011, John was admitted to emergency at the Janeway Hospital in St. John's on several occasions. Each time, he was deemed not to be an immediate threat to himself or others, and he was discharged with instructions to follow up with counselling and other medical services.
During that time, a social worker talked off and on with John's mother, who repeatedly told the worker that her son appeared to have major mental health issues. John's mother said she was doing her best to help him, but she was raising him on her own while holding down two jobs.
She said although John had supportive grandparents and other relatives, they felt they were unable to handle him.
She said John had not brushed his teeth regularly in three years, he was failing at school, and he had threatened to kill himself and her.
She said John believed there was something wrong with his brain, but that his family doctor would not prescribe medication until John had a psychiatric assessment.
Yet, John's mother said a doctor told her that "a psychiatrist will not see John until he has stopped using drugs."
Mother files charges to get son help
Eventually, during the winter of 2011, a doctor advised John's mother to file charges against him, to protect herself and fast track John into help.
John went into detox treatment. In April 2011, he told a community youth worker he was hearing voices. The youth worker suggested he make an appointment with his family doctor and ask for a mental health assessment.
John and his mother attended one assessment with a psychiatrist, who did not prescribe medication.
The next few months were a whirlwind of recommendations for John and his mother to follow up with assessments and counselling. All that time, John's mother insisted he needed psychiatric help, and that he was not a good candidate to live on his own.
During this period, John was removed from his home, he turned 16, and after bouncing around between emergency and temporary shelters, he was placed in the boarding house on Springdale Street.
John's mother and social workers reported he looked increasingly haggard, and still struggled with alcohol and drugs. He was arrested for theft.
In another admission to the Janeway, John said he had thoughts of burning down the house where he was living.
Man dies in boarding house fire
Two years and five months after John's mother first contacted the RNC, a man died in a boarding house fire, and once more, police were called.
On Nov. 27, 2011, John was taken into custody on a number of charges, including manslaughter and arson.
In May 2012, he pleaded guilty.
The child and youth advocate's report is full of appendices, methodologies, mandates, and recommendations. It is full of words such as , "research," "review," "feasibility," "procedures," and "implementation."
It does not say where the boy is today, or whether he and his mother are getting the help they need. .Suggest a correction