All child deaths are tragic and typically have a number of contributing factors.  Occasionally, the actions or inactions by those in a caregiving role (e.g. family members or the child welfare system) may have played a part in the circumstances of the death. The Paediatric Death Review Committee (PDRC) – Child Welfare reviews the circumstances of the death and may make recommendations to the health care sector, child welfare systems and others with a goal to reduce the number of child deaths and/or to improve the services and care provided to children, youth and families. It is anticipated that by examining these cases with a non-blaming approach, we can learn from individual deaths to improve the lives of other children.

Reports received by the PDRC – Child Welfare in 2016 and 2017

PDRC – Child Welfare cases reported to the Committee are usually not reviewed within the same calendar year in which death occurs.  Committee reviews in any given year will include review of deaths occurring in different years (see Chart 24).  This results from a number of factors, including: complexity of the investigation, time allotment for completion of other reviews (for example, DU5C), case volume, and other parallel investigations or proceedings, including involvement of the criminal justice system.

In 2016, as required by the Joint Directive, Societies reported the deaths of 121 children and youth to the PDRC – Child Welfare, which included 115children and youth aged 0-18 years and 6 deaths of youth aged 19-21 years, where the child and/or family had Society involvement within 12 months of the death.  In 2017, 126 deaths of children and youth were reported by Societies to the PDRC – Child Welfare, which included 122 children and youth aged 0-18 and four youth aged 19-21. These cases are at various stages of the PDRC review process. 

Chart 23A: PDRC status of 2016 deaths with Society involvement

Chart 23A illustrates the status of review for the 121 cases reported to the PDRC – Child Welfare in 2016. 60 of cases did not require a full PDRC review.

Chart 23a
Status Number of Cases
Closed A PDRC Executive Review has taken place, and no full PDRC review is planned.  This occurs when the circumstances surrounding the child’s death do not relate in any way to the reasons for services and/or the Society involvement. 72 (60%)
Pending Decision Cases may be pending a decision regarding PDRC review because additional information is required or because there are other pending investigations or  criminal justice system involvement 23 (18%)
Full PDRC Review to be Undertaken An internal child death review has been requested from the Society, and the PDRC will undertake a full review of the case. 13 (10%)
Full PDRC Review Completed An internal child death review was requested from the Society, and the PDRC has undertaken a full review of the case. 13 (10%)

Chart 23B: PDRC status of 2017 deaths with Society involvement

Chart 23B illustrates the status of review for the 126 cases reported to the PDRC – Child Welfare in 201745% of cases do not require a full PDRC review and 36% of cases are pending a decision.

Chart 23b
Status Number of Cases
Closed A PDRC Executive Review has taken place, and no full PDRC review is planned.  This occurs when the circumstances surrounding the child’s death do not relate in any way to the reasons for services and/or the Society involvement. 57 (45%)
Pending Decision Cases may be pending a decision regarding PDRC review because additional information is required or because there are other pending investigations or criminal justice system involvement 43 (34%)
Full PDRC Review to be Undertaken An internal child death review has been requested from the Society, and the PDRC will undertake a full review of the case. 15 (12%)
Full PDRC Review Completed An internal child death review was requested from the Society, and the PDRC has undertaken a full review of the case. 11 (9%)

Reports reviewed by the PDRC – Child Welfare in 2016 and 2017

In 2016, following the process outlined in Chart in Appendix A, the PDRC - Child Welfare reviewed the deaths of 32 children and youth who had involvement with a Society within the 12 month period leading up to their deaths; in 2017 the number of deaths reviewed was 13.   Fewer cases were reviewed in 2017 than in previous years due, in part to the work being conducted in preparation for an Expert Panel which reviewed the deaths of 12 young people in residential care; and to the efforts dedicated to the establishment of the Child and Youth Death Review and Analysis (CYDRA) Unit.

Chart 24: Year of death of 2016 and 2017 PDRC case reviews

Chart 24 illustrates the year of death for those cases reviewed by the PDRC – Child Welfare in 2016 and 2017.  The majority (22) of the 32 cases reviewed in 2016 were of deaths that occurred in 2014 and 2015.  The year of death for those cases reviewed in 2016 ranged from 2011 – 2016.  For the majority of cases reviewed in 2017, the deaths occurred in 2015 through to 2017 with one case from 2013.

Chart 24
Year of Death PDRC Cases Reviewed in 2016 PDRC Cases Reviewed in 2017
2011 1 0
2012 2 0
2013 3 1
2014 12 0
2015 10 4
2016 3 5
2017 n.a. 3
TOTAL 32 13

Of the 32 cases reviewed by the PDRC in 2016, 19 were males (59%) and 13 were females (41%).

The age of the children and youth at the time of their death ranged from 5 days to 20 years.

Of the 13 cases reviewed by the PDRC in 2017, 5 were males (38%) and 8 were females (62%).

The age of the children and youth at the time of their death ranged from 42 days to 17 years.

Historically, a greater proportion of reviews completed by the PDRC – Child Welfare involve children under one and adolescents. Chart 25A and Chart 25B demonstrate the age categories for the cases reviewed. This information illustrates that in 2016, approximately 1/3 of the PDRC – Child Welfare’s reviews focused upon deaths of children under the age of five, 1/3 on children and youth age 10-14 and 1/3 on those age 15-18 with a small percentage on those age 1-4 and 5-9.  There was a different focus for the reviews conducted in 2017 as can be observed in Chart 25B, more than half of the 13 reviews were for deaths of individuals in the 10-14 year age group.  This is partly as a result of a decision by the PDRC to stop inclusively reviewing deaths where the manner of death is undetermined and unsafe sleep environment is listed as a factor.  The decision to stop the review of these types of deaths was made because on reflection, of the many reviews conducted, substantive new information was not being gained and recommendations were uncommon from these reviews. 

Chart 25A: PDRC – Child Welfare reviews across age groups 2016 (n=32)

  • Chart 25A demonstrates the age categories for the cases reviewed in 2016. This information illustrates that in 2016, 28% of the PDRC – Child Welfare focused upon deaths of children under the age of one, 31% on youth age 10-14, 28% on youth age 15-18, 6% on those age 5-9 and 6% on those age 1-4.

Chart 25B: PDRC – Child Welfare reviews across age groups 2017 (n=13)

  • Chart 25B demonstrates the age categories for the cases reviewed in 2017. This information illustrates that in 2017, 54% of the cases reviewed at PDRC – Child Welfare focused on the deaths of children and youth age 10-14, 31% on those age 15-18 and 16% on those under the age of five.

Chart 26A: PDRC – Child Welfare reviews across manner of death in 2016 (n=32)

  • Chart 26A illustrate the manner of death of children and youth whose cases were reviewed by the PDRC – Child Welfare in 2016. The highest number of cases reviewed in 2016 were suicides (11), followed by undetermined (7) and homicide (7), accidents (4) and natural deaths (3).  

Chart 26B: PDRC – Child Welfare reviews across manner of death in 2017 (n=13)

  • Chart 26B illustrates the manner of death of children and youth whose cases were reviewed by the PDRC – Child Welfare in 2017. In the majority of cases for 2017 (8 out of 13 deaths), the manner of death was suicide, followed by two homicides and one accident, natural and undetermined death each.

Of the 32 deaths reviewed by the PDRC – Child Welfare in 2016 where the manner of death was undetermined (n=8), sleep circumstances were identified as a potential contributing factor in two cases (25%).

Of the 32 cases reviewed by the PDRC – Child Welfare in 2016, 41% (13) were open to the Society at the time of death (see Chart 27AIn 2017, 62% (8) of the cases reviewed by the PDRC were open to a Society at the time of death (Chart 27B).

Of the 13 cases open to a Society in 2016, four were in the stages of investigation and assessment, eight were in ongoing protection intervention, one was under protection support, and one was being provided family support/community link/non-protection. Two individuals were in Extended Society Care, one was in Temporary Society Care under a foster care placement and two were in receipt of CCSY. The manners of death for the three children and youth in care in 2016 were undetermined (one), suicide (one) and natural (one).

Of the eight cases open to a Society in 2017, two were subject of a formal customary care agreement, one was under a supervision order, one was receiving protection support and one was living semi-independently under Extended Society Care. The manners of death of the two youth that were in care at the time of their death were both suicide.

Chart 27A: PDRC – Child Welfare reviewed cases in 2016 open vs. closed (n=32)

  • Chart 27A illustrates that of the 32 cases reviewed by the PDRC – Child Welfare in 2016, (41%) were open to a Society at the time of death, while 59% of cases were closed to a Society at the time of death. 

Chart 27B: PDRC – Child Welfare reviewed cases in 2017 open vs. closed (n=13)

  • Charts 27B illustrates that of the 13 cases reviewed by the PDRC – Child Welfare in 2017, eight (62%) were open to a Society at the time of death, while 38% of cases were closed to a Society at the time of death.