Child welfare services in Ontario are provided by 38 independent children’s aid societies and eleven Indigenous child wellbeing societies (“Societies”) to deliver child protection services, for a total of 49 societies.  All societies receive provincial funding from the Ministry of Children, Community and Social Services (MCCSS), formerly known as the Ministry of Children and Youth Services (MCYS).

By policy, coroners in Ontario investigate all paediatric deaths where a Society has been involved with the child, youth or family within 12 months of the death. In 2006, the OCC and the MCCSS implemented a Joint Directive on Child Death Reporting and Review. The Directive outlines the process Societies must follow when reporting and reviewing child deaths when they have been involved with the child, youth or family within 12 months of the death (see Appendix A for more information).

Stemming from the process outlined in the Directive, there are three distinct information sets that are relevant to Societies, the government and the public, resulting from:

  1. The death investigation by the coroner;
  2. Children’s aid society / Indigenous child wellbeing society reporting related to these deaths; and
  3. PDRC - Child Welfare reviews completed in certain circumstances.

This annual report presents an analysis of this information, to support data driven public safety, by:

  • Comparing paediatric deaths with Society involvement to paediatric deaths without Society involvement;
  • Conducting an analysis of data about paediatric deaths where there has been Society involvement; and
  • Providing recommendations in an effort to prevent further deaths.

Prior to 2014, the PDRC – Child Welfare’s annual report focused on an analysis of PDRC case reviews.  More can be learned from considering all paediatric deaths with Society involvement, using the information provided by Societies in relation to those deaths.   For this reason, this year’s annual report follows the same approach as the 2014, 2015 and 2016 reports.

The PDRC – Child Welfare and the OCC believe that this data is valuable to provide a better understanding of paediatric deaths with Society involvement in Ontario. The OCC continues to receive feedback from many parties about the value of the approach and the utility of the information.  It is hoped that by continuing to provide the additional analysis this will  assist Societies, policy makers, researchers and the public to identify relevant areas to develop strategies and policies to help prevent further deaths. 

Use of data by the PDRC – Child Welfare

There are a number of challenges with the data available for analysis that merit consideration when reading this report, including:

  • The data is primarily collected by coroners from across the province. Limits in standardization and non-confirmation of data accuracy may affect the analysis.  The OCC is developing a new data capture system that is expected to significantly improve the quality and completeness of the OCC’s data.  The development of this system is underway with implementation anticipated in 2019.
  • The lack of comparator data from other sources. Data from different sources is collected with varying sets of parameters, depending on the needs of the organization. Some of the data required for effective comparison is unavailable. Other data sets are incomplete, or are measured in ways that do not align with the data that the OCC and the PDRC collect. 
  • There are varying interpretations of the Joint Directive on Child Death Reporting and Review.  We are not proceeding with clarification of the Joint Directive at this time, pending the development of a new model of child death review, to avoid potential duplication of efforts.

In August 2016 a standardized, PDF fillable Child Fatality Case Summary Report was implemented. This has significantly enhanced the consistency in the data collected from Societies.  As implementation took place part way through the year, there continues to be some variability in the data collected.

Where an analysis of the five available years of data, 2013 – 2017, was feasible, the results have been included in the report.  The data analyzed to-date suggests that there is sufficient variability within the data year-over-year to merit the ongoing examination of the data prior to drawing any conclusions.  As time passes and larger data sets are developed the ability to identify trends or draw conclusions from the data will improve.  At this time, the significance of some available data is unknown. 

PDRC – Child Welfare’s approach to statistical analysis

As in previous years, statistical analysis was completed to determine how “close” observed rates of paediatric deaths are to that expected in the context of one of two standard populations – paediatric coroner’s investigations, or child deaths in Ontario. 

In some cases, no statistical analysis could be completed because of limitations arising from the nature of the data, the size of the populations, or challenges with data as discussed above.

In this section of the annual report, basic statistical analyses have been utilized to support the presentation of available data.

Looking forward: Data-driven death review

Since 2014, the OCC has been working with the Ministry of Children, Community and Social Services (MCCSS) and the Office of the Ontario Child Advocate (OCA) to develop a “best-in-class” model of child and youth death 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, and research and prevention strategies in the province of Ontario.  All three parties have provided funding to support a Child and Youth Death Review and Analysis Project Team that will be working to implement a new model of child and youth death review over the next two years. To date, the framework for a new model has been developed and pilot projects are expected to be completed by 2020.

Ultimately, the objective of a new model is to improve the health, safety and well-being of Ontario’s children and youth and reduce the child mortality rate in Ontario.  We recognize that the factors that influence the circumstances of a person’s death are not isolated to the immediate time surrounding their death; they have intersected with various systems throughout the course of their life, and those systems may have influenced the circumstances of their death. Consequently, to be maximally effective, a new model of child and youth death review and analysis requires integrated data regarding the circumstances of a person’s death and their intersections with systems over their life course. This is key to determining the right areas for targeting further analysis, prevention strategies and areas where research could be of benefit. 

To achieve this vision, the new model will leverage data (existing and/or new) to undertake surveillance and identify trends and themes that may point to broader systemic issues – and therefore, target the “right” areas for further analysis to promote and advance death prevention. The OCC is actively working with a number of key governmental partners on designing a data integration pilot that will inform the next steps for Ontario’s model of child and youth death review. Full implementation of the new model is anticipated following the pilot’s evaluation.