Paediatric Death Review Committee: Medical and Child and Youth Death Review and Analysis 2019–2021 report
Read the committee’s report reviewing paediatric, child and youth deaths in Ontario in 2019–2021.
Introduction
Ontario's death investigation system is the largest in North America. In Ontario, coroners are medical doctors with training in the principles of death investigation. Coroners investigate deaths in accordance with Section 10 of the Coroners Act. In 2021, the Office of the Chief Coroner (OCC) investigated approximately 16% of all deaths that occurred within the province.
The OCC investigates deaths involving non-natural causes — for example, injuries (both intentional and non-intentional) and those that occur suddenly and unexpectedly — to understand the circumstances of the deaths and potentially provide recommendations to prevent further deaths.
Investigations are also completed into deaths that occur in certain settings, for example, correctional facilities and under such circumstances where an investigation is believed to be required.
Death investigation services are provided by the OCC and the Ontario Forensic Pathology Service (OFPS). Together, they form a division within the Ministry of the Solicitor General (SOLGEN). The OCC partners with the OFPS to ensure a coordinated and collaborative approach to conduct death investigations in the public interest.
Definitions when determining the manner of death
The OCC applies the following definitions when determining the manner of death:
Natural: Cause of death was a disease, or a complication of its treatment. Injury did not cause or substantially contribute to the death.
Accident: Cause of death was an injury where death was not intended or foreseen. Inflicted injury did not cause or substantially contribute to the death.
Suicide: Cause of death was an injury which was non-accidentally inflicted by the deceased.
Homicide: Cause of death was an injury which was non-accidentally inflicted by a person other than the deceased.
Undetermined: Cause of death could not be selected from the classifications of Natural, Accident, Suicide and Homicide because the evidence either:
- was inadequate (for example, skeletal remains)
- was equal for two or more classifications, or so nearly equal that they could not be confidently distinguished
- did not reasonably fit the definitions of the four classifications
Child and youth deaths
The OCC investigates approximately 43% of all child and youth deaths that occur within Ontario each year. The investigation and review of child and youth deaths is an area that continues to be one of the most important and challenging areas within the OCC’s mandate. The deaths of children and youth are challenging from both emotional and investigative perspectives.
The OCC has taken several measures over the last few years to enhance child and youth death investigation and review.
The Child and Youth Death Review and Analysis
The Child and Youth Death Review and Analysis (CYDRA) Unit within the OCC has been developing and transforming the processes for child and youth death reviews. The former Paediatric Death Review Committee – Child Welfare (PDRC-CW) has been replaced by several distinct death review processes. The PDRC-CW was a standing committee specific to the child welfare sector, limited to reviewing the deaths of young people involved with the child welfare system within the 12 months preceding their death. The current review structures are designed to evolve through collaborative transformation, which is why the word ‘interim’ is used for some of the current review processes.
The purpose of child and youth death reviews is to explore the circumstances related to the child or youth's death in order to honour their lives, learn from them, and make recommendations that may enhance the overall well-being of young people and contribute to the prevention of further deaths.
CYDRA review processes
Under CYDRA, the type of review is informed by the circumstances of the death and the specific issues to be explored. Currently, the review processes that are in place under CYDRA include:
- Local Death Review Tables are an intersectoral approach to death review in which individuals who worked directly with the child/youth are brought together in addition to individuals with specialized knowledge specifically relevant to the death to review the journey of the deceased child or youth.
- Two interim Paediatric Death Review Committees for Children and Youth (PDRC-CY), one for review of deaths of Indigenous children and youth and the other for non-Indigenous children and youth. These death review processes are not limited to child welfare-specific deaths and may include deaths where other systems, such as education and youth justice, are involved.
- Expert reviews by subject matter experts will evaluate specific issues identified during the initial death investigation and review.
- Local Reviews co-developed through First Nation led Protocols. As a part of the collaborative transformation, CYDRA is working with First Nations (where invited) to develop local protocols for Indigenous child and youth death reviews.
The new processes look beyond the child welfare system and include deaths that may be referred to CYDRA by the local coroners or Regional Supervising Coroners, the Office of the Ombudsman of Ontario, the Ministry of Children, Community and Social Services (MCCSS), or other child and youth serving systems, such as the education system. For this reason, each death reported and/or referred to CYDRA is reviewed on an individual basis to inform potential further review and recommendations.
It is recognized that the factors that influence a person’s journey are not isolated to the immediate circumstances surrounding their death. Children and youth intersect with various systems throughout the course of their lives, and those systems may influence the specific circumstances that contributed to the death of the child or youth. Consequently, an effective death review process requires integrated data regarding the circumstances of a person’s death and their intersections with systems. An intersectional analysis of this data is the key to targeting further analyses, prevention strategies and areas where future research could be of benefit.
CYDRA principles
The following principles underpin the work of CYDRA:
Intersectional approach
Social identity is complex and multifaceted, and several social factors intersect to determine social location of an individual. Therefore, it is important to collectively analyze the factors that affect individuals’ lives rather than considering them in isolation. Systems and structures are underpinned by colonialism and racism which can produce distinct experiences, especially for Indigenous and racialized populations.
Colonialism is real and ongoing
First Nations, Inuit and Métis children and youth have been, and continue to be, overrepresented within the child welfare system. These children and youth are disproportionally impacted by racism and colonization, which are manifested in policies and actions such as the Sixties Scoop, Indian Residential School System, and the ongoing Millennial Scoop. Understanding the role of racism and the harmful impacts that it continues to have is critical to preventing further deaths.
Anti-Black racism is real
Black children, youth and families are overrepresented in child welfare and other youth-serving systems, and as a result, they experience barriers, oppression and disparities within those systems as a function of systemic racism.
Trauma is complex
Understanding how trauma manifests in life choices and outcomes is critical to understanding young people and their journeys.
Death prevention is a shared responsibility
Recognizing that death prevention is a shared responsibility, and that children, youth, families, and communities are impacted by multiple systems, the death review processes aim to understand how these systems impact lived experiences and incorporate multiple organizations at various levels to inform the death investigation and review process.
With broader input and participation, there will be increased opportunity for timely, relevant learning for all involved. Similarly, comprehensive data will be available to inform prevention and identify trends and themes that can point to systemic issues. CYDRA is supported by a specific policy directive between the OCC and the Ministry of Children, Community and Social Services (formerly Ministry of Children and Youth Services). The 2006 Joint Directive on Child Death Reporting and Review
Historically, the process for reporting child and youth deaths to the OCC has been through the Joint Directive. However, it is recognized that further work is needed to collaborate on an enhanced reporting mechanism to include the reporting of deaths not covered under the 2006 Joint Directive, so that the policy better aligns with the transformation work being undertaken at CYDRA. While the 2006 Joint Directive is still in place, deaths with no child welfare involvement but where potential systems issues are identified can be referred to CYDRA in a variety of ways, as mentioned above (for example, those recommended by the coroners, First Nations, Ombudsman Office and Ministries).
This Annual Report will centre the analysis and findings of the data collected by the OCC for children and youth who died between 2019—2021, inclusive.
Contacts
Child and Youth Death Review and Analysis Unit
Dayle Espiritu – Senior Program and Policy Lead/Specialist
Tanrima Moumita - Senior Research and Statistics Advisor
Dr. Joel Kirsh, BASc, MSc, MD, MHCM, FRCP(C)
Chair, Paediatric Death Review Committee - Medical
Regional Supervising Coroner, Central East Region
Footnotes
- footnote[1] Back to paragraph This directive is issued under section 20.1 of the Child and Family Services Act and replaces the October 1, 2000 joint directive on child death reporting and review