06/15/2016 02:40 EDT | Updated 06/15/2016 02:59 EDT

J'Lyn Cardinal's Fatality Inquiry Shows How The Alberta System Failed Her

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'In a deep depression' concept

A fatality inquiry has exposed the heartbreaking story behind an Edmonton preschooler's death.

"This is a very sad and complicated set of circumstances," said Provincial Judge Joyce Lester in a report, which explained how a inexperienced caregiver with a troubled past came to be the guardian of her brother's six young children.

The woman, who is identified as just S.D.C. in the report to protect the other kids' identities, pleaded guilty to manslaughter of her four-year-old niece J'Lyn Cardinal in 2010.

Cardinal died from a major head injury; police found her lying on her back, wearing only a diaper on the floor of her aunt's home.

At the time, S.D.C. was taking care of six kids aged eight months to seven years.

"This is a very sad and complicated set of circumstances."

S.D.C. grew up in a family that received assistance through child services. She was hospitalized for mental health struggles and was allegedly abused as a child, according to the inquiry report.

When she was just 23, she applied to become caretaker of the kids. Her brother and the children's mother were both struggling with homelessness and addictions.

For the first few months of taking care of the kids in 2008, S.D.C. brought them to appointments and school. In the weeks leading up to her death, Cardinal started missing school.

Aunt was 'essentially on her own'

S.D.C. wasn't receiving support from her extended family, and Kinship Care — the program that made her the children's guardian — rarely visited her home.

"Despite the Christmas season often being considered a very stressful time for many families, in many homes, S.D.C., with her added responsibilities and expanded family, was essentially on her own," the report reads.

On Jan. 12, 2009, the day before Cardinal's body was found, S.D.C. spoke on the phone with a social service worker about possibly bringing in her mother to help her with taking care of the children.

'A troubling situation'

Alberta's Kinship Care program was established under the premise that the best place for children in need is with their extended family, rather than in a stranger's foster home.

"It is a troubling situation and a fine act of balance when the kinship placement may well be as dysfunctional an environment as the home from which the subject children are being extracted," reads the inquiry.

The judge's inquiry offered recommendations for preventing similar tragedies to Cardinal's death. It suggested that caregivers not be overburdened with too many young children, and that the program look into how experienced the caregiver is.

It noted there should be an extensive look into prospective caregiver's backgrounds, rather than relying on them to self-report.

The judge also recommended employees of the care program spend more time prepping caregivers and checking in on them in order to give them as much support as possible.

Four children have died so far this year while in government care, which includes foster homes.

S.D.C. is currently serving a seven-year sentence for Cardinal's death.

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