Child and Youth Death Review and Analysis Unit

Overview

The Office of the Chief Coroner has a dedicated unit for child and youth death review and investigation, referred to as Child and Youth Death Review and Analysis (CYDRA). A primary focus of the work is to review and investigate deaths of children and youth where there was involvement with child and youth-facing service systems. This could involve interaction with child welfare, the youth justice system, children and youth mental health, or the education system.

The goal of child and youth death review is to reduce child and youth deaths, make service-level, systemic, and structural recommendations aimed to prevent deaths, and to contribute to public safety by supporting recommendations that enhance the overall well-being of children, youth, their families, and communities.

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 contribute to the prevention of further deaths.

Death review processes

Each of child and youth death reported is evaluated and considered for further review or investigation. Where it is determined that further review would be beneficial, deaths are reviewed through a process that best honors and respects the child or youth and one that will contribute to learning.  CYDRA reviews information from Serious Occurrence Reports, Child Fatality Case Summary Reports, and coroner’s investigation statements as part of the decision-making process. A number of other criteria are also considered, including factors based on research and best practice.

Examples of death review processes for children and youth are outlined below:

• Interim Paediatric Death Review Committee-Children and Youth (PDRC-CY) - Indigenous
• Interim Paediatric Death Review Committee - Children and Youth (PDRC-CY) – non-Indigenous
• Local Reviews co-developed through First Nation led Protocols
• Local Death Reviews Tables
• Expert Reviews
• Other Death Review Processes (for example, case conferences)

Careful attention and thought is included in each death review, including a comprehensive review of information and working with experts and sectors to determine who best participates in the review. Each death is unique in terms of the review process depending on the individualized factors related to the young person and their experience (For more information, see Appendix A).

Child welfare – society and agency Involvement

Child welfare services in Ontario are provided by thirteen (13) Indigenous Child and Well-being Agencies, and thirty-seven (37) Children’s Aid Societies. Under the Joint Directive on Child Death Reporting and Review^{footnote 1[1]}, coroners in Ontario investigate all paediatric deaths where a Society/Agency has been involved with the child, youth or family within 12 months of the death.

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

• comparing child and youth deaths with Society/Agency involvement to deaths without Society/Agency involvement
• providing recommendations in an effort to prevent further deaths

Use of data by CYDRA – child welfare or Indigenous child and family well-being

This section of the annual report presents summary statistics to compare and observe the child and youth population in Ontario in the context of Society/Agency involvement. Descriptive statistical analyses have been utilized to support the presentation of available data. The results of the data from the years 2019—2021 are included in this report.

The data analyzed to date suggests that there is sufficient variability 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 not known due to insufficient data points.

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. There are several challenges with the data available for analysis that merit consideration when reading this report.

The data is collected primarily by coroners from across the province. Limits in standardization and non-confirmation of data accuracy may affect the analysis.  The OCC has developed a new data capture system, QuinC, that is expected to improve the quality and completeness of the OCC’s data with implementation in 2021.

The lack of comparator data from other sources is another significant barrier to inferential and comparative analyses. Data from different sources is collected with varying sets of parameters, depending on the organization’s needs. 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 CYDRA collect.

Understanding the role of natural deaths with child welfare involvement and deaths still under investigation

By policy, coroners in Ontario investigate all paediatric deaths of children and youth where a Society has been involved with the child, youth or family within 12 months of the death. Consequently, some paediatric deaths that would not ordinarily meet the criteria for a coroner’s investigation are investigated solely because of the involvement of a Society/Agency. These deaths include natural deaths that occurred in a hospital/hospice or that were expected to occur, which under normal circumstances would not likely be investigated by a coroner. These deaths are excluded from the analyses undertaken in this report to allow for the comparison of deaths with Society/Agency involvement against the cohort of paediatric coroners’ investigations (which does not include natural deaths free of care related concerns). From 2019 to 2021, 44 child and youth deaths fell into this category and have been removed from the analysis.