There have been a number of achievements made over the past two years in advancing child death investigation and review. This area continues to be one of the most important and challenging parts of our mandate.  The Paediatric Death Review Committee (PDRC) and Deaths Under Five Committee (DU5C) exist to help us learn from child deaths in order to help prevent further deaths.  Each opportunity to learn offers an important opportunity to reduce child mortality - potentially sparing the profound grief families suffer when a young life full of promise is lost prematurely.

Enhancing these opportunities to learn is a priority for the Office of the Chief Coroner (OCC) and for others. Since 2014, we have been working with the Ministry of Children, Community and Social Services (MCCSS), formerly known as the Ministry of Children and Youth Services (MCYS) and the Office of the Ontario Child Advocate (OCA) to develop a “best-in-class” model of review that will be data-driven, evidence informed and grounded in collaborative partnerships. This will maximize the potential for affecting public health analysis, policy development, research and prevention strategies in the province of Ontario.

The Child and Youth Death Review and Analysis Team (CYDRA) has been operational since December 2017 and has been granted two year-funding through by a tripartite agreement between the Office of the Chief Coroner, the Ontario Child Advocate and the MCCSS.

Recognizing that death prevention is a shared responsibility and that children, youth and families are impacted by multiple systems, the new model will incorporate multiple organizations at various levels to thoroughly inform the death investigation and review process at each stage. With broader input and participation, there will be increased opportunity for timely, relevant learning, and more comprehensive data will be available to inform surveillance and help to identify trends and themes that can point to systemic issues. This is key to determining the right areas for targeting further analysis, prevention strategies and areas where research could be of benefit. 

We are in the process of developing a pilot project, and expect to be engaging with our community members on this topic in 2019.

While the new model is under development, the PDRC and DU5C have continued their valuable work.  Their thoughtful analysis continues to identify important recommendations that can make a significant contribution to community safety and are instrumental in bringing preventative strategies to the attention of organizations.  I am grateful for the hard work of the committee members and their ongoing commitment to child death review.  Their work is well documented in this annual report.

I am pleased to report that Jessica Diamond, who held the Executive Lead, Child Welfare position and completed the foundational work to inform the new CYDRA approach, has become Manager, Children in Care at MCCSS. . We congratulate Jessica and thank her for all the commitment, leadership and hard work during her time with the OCC. We are pleased that Peggy McPhail joined our organization shortly after Jessica’s departure. Peggy has hit the road running!  

I look forward to continued work with others toward the shared goal of improving the health, safety and well-being of Ontario’s children and youth.

Dirk Huyer, MD
Chief Coroner for Ontario
Chair, Paediatric Death Review Committee and Deaths Under Five Committee