Newfoundland and Labrador's advocate for children and youth reviewed the care offered the troubled teen who was convicted after a trapped man died in the November 2011 blaze as horrified witnesses watched.
Carol Chafe said the teen, who was sentenced to three years in intensive rehabilitative custody after pleading guilty to manslaughter, fell through wide gaps in the child welfare system.
Her report, "Sixteen," blasts the government for collaboration failures and policy breaches. It also repeats criticisms Chafe has made before.
"Sixteen is the story of a young person crying for help," she told a news conference. "Due to deficiencies within the system, there were times when his voice was not heard, his rights were not respected and his right to services was not upheld."
Chafe makes 30 recommendations aimed at the provincial departments of child, youth and family services, justice and health. She said frontline workers must give troubled teens a say in their fate but also assess their competence to make "life-altering decisions."
Chafe said the boy, who can't be identified because of his age at the time, was removed from his mother's care weeks before he turned 16.
"There were multiple missed opportunities to fully assess (his) circumstances prior to him coming into care," says the report. It notes that "multiple social workers documented significant issues, including: selling drugs, using drugs, mental health concerns, parent-child conflict, suicidal ideation, injuries and homelessness."
Despite those red flags, the teen "was left in potentially unsafe circumstances" through 2010 and into early 2011, says the report.
At 16, he signed a youth services agreement and moved from a supervised residence into a shelter. He lived in more than one temporary home.
Chafe's report includes excerpts from an interview with the teen in which he recalls telling hospital staff in late 2011 that "he had thought about harming himself."
"Everything just clashed and clashed, and I told them that I needed help, whatever, but nobody listened," he is quoted as saying.
He would later admit in an agreed statement of facts that he set the fire when he was distraught over a breakup with a girl and after drinking beer and rum.
The rooming house fire broke out Nov. 27, 2011, killing Carlos Escobar Medina, 54.
Chafe's report included 40 interviews, including the boy and his family, and a review of policy and procedures. It cites a lack of co-operation between social workers, police and health staff.
Chafe also points out major record-keeping issues.
"Throughout this investigation there was evidence of a profound lack of collaboration and sharing of relevant information by all departments and agencies involved," she said.
Her recommendations include calls for more training for social workers, better planning and adherence to policy.
Paul Davis, the provincial minister for child, youth and family services, said his department has improved services since 2011 and will meet with Chafe to discuss each recommendation.
"We are committed to working with the advocate," he told a news conference. Davis set no timeline for action.
But he said the number of managers for frontline social workers has increased to 13 from five and that files are randomly audited each month. Davis said a new training unit is also in place.
The minister conceded, however, that the department's risk management system is "not the newest, most modern system that's available." He said officials are assessing new technologies.
Sheldon Pollett, executive director of Choices for Youth in St. John's, said the teen was one of 600 clients the program supports each year.
"We have a desperate shortage of appropriate, supportive, affordable housing in this province."
Liberal Opposition critic Andrew Parsons said the Progressive Conservative government's shortcomings in this case amount to "gross negligence."
"It's sad, really, when you hear about the tragic lack of communication and the lack of documentation."
The teenager at the heart of the case hopes the ordeal for all concerned was not in vain.
"I hope it isn't all for nothing," he is quoted as saying in Chafe's report. "I just hope this doesn't happen to somebody else really, it sucks."