Child and youth death review: analysis
Child and youth deaths with Society/Agency involvement compared to other child and youth deaths in Ontario (2019—2021)
In 2021, there were 1,062 deaths of children and youth aged 0—19 (inclusive) in Ontario, of which, 456 deaths met the criteria for a coroner’s investigation. Of the paediatric deaths investigated by a coroner in 2021, 101 (22%) were reported to CYDRA because of Society/Agency involvement with the child, youth, or family within 12 months prior to the death. This is consistent with the proportion of deaths investigated previously in this age group.
In addition to the 101 deaths reported by a Society/Agency in 2021, Societies/Agencies also reported the deaths of 16 youth (ages 20—22 years). As these 16 youth were receiving Continued Care and Support for Youth (CCSY) from a Society/Agency at the time of their death or case closure, they were included in this analysis (total age 0—22 with Society/Agency involvement = 117).
Chart 6: Child and youth deaths Investigated by the OCC with Society/Agency involvement, 2019—2021
| Year | Ontario deaths (age: 0—19 years) | OCC investigated (age: 0—19 years) | CYDRA – Society/Agency Involved Age: 0—19 years | CYDRA – Society/Agency Involved Age: 20—22 years | CYDRA – Society/Agency Involved Total (age: 0—22 years) | |
|---|---|---|---|---|---|---|
| 2019 | 1,132 | 491 | 104 | 5 | 109 | |
| 2020 | 1,029 | 436 | 80 | 2 | 82 | |
| 2021 | 1,062 | 456 | 101 | 16 | 117 |
Chart 6 provides the number of child and youth deaths in Ontario, investigated by the OCC, and with Society/Agency Involvement as reported to CYDRA from 2019 to 2021. Between 2019 and 2021, approximately 22% of all deaths investigated by the OCC had a Society/Agency involvement.
Chart 7: Number of deaths of children and youth by age group with Society/Agency involvement, 2019—2021
Between 2019 to 2021, the highest number of deaths with Society/Agency involvement were among infants and toddlers between the age 0 to 4 years, followed by youth between 15 and 19 years. There was an increase in the number of deaths among the age group 20+ years, increasing from two deaths in 2020 to 16 deaths in 2021.
Chart 7.1: Number of deaths of children and youth by manner of death with Society/Agency involvement, 2019—2021
Please note that two deaths from 2020 and two deaths from 2021 were not included in Chart 7.1. No manner of death had been determined as they were not investigated by the OCC.
Between 2019 to 2021, the highest number of deaths with Society/Agency involvement had a manner of death classified as accidental, followed by undetermined. There was an increase in the number of deaths with a manner of death classified as accidental increasing from 23 deaths in 2020 to 42 deaths in 2021.
Please note that two deaths from 2020 and two deaths from 2021 were not included in Chart 7.1. No manner of death had been determined as they were not investigated by the OCC.
Accidental deaths
Similar to the findings of accidental deaths among all children and youth investigated by the OCC, the most common death factor among those with Society/Agency involvement was acute drug toxicity, which accounted for 47% of all accidental deaths.
Deaths with Society/Agency involvement – In care
Children and youth were counted as being ‘in care’ when they were identified by the Society/Agency as being in extended Society/Agency care, interim Society/Agency care, were the subject of a temporary care agreement, or were in ‘kinship care’. Individuals who are legally ‘in care’ may be in various living arrangements, including foster care, residential care or may be temporarily staying with family at the time of death.
A child or youth in ‘Customary Care’ is a First Nations, Inuit, or Métis young person, legally in the care of a person who is not the child’s parent, according to the custom of the child’s band, First Nation, Inuit or Métis community.
Deaths with Society/Agency involvement –VYSA or CCSY
Voluntary Youth Services Agreement (VYSA) is an agreement under Section 77(1) of the Child, Youth and Family Services Act (CYFSA) between a society and a youth who is 16 or 17, for services and supports to be provided for the youth where,
- the society has jurisdiction where the youth resides;
- the society has determined that the youth is or may be in need of protection;
- the society is satisfied that no course of action less disruptive to the youth, such as care in the youth’s own home or with a relative, neighbour or other member of the youth’s community or extended family, is able to adequately protect the youth; and
- the youth wants to enter into the agreement.
Continued Care and Supports for Youth (CCSY) is for eligible youth aged 18 extending to their 21st birthday. CCSY provides youth with financial (minimum of $850/month) as well as non-financial supports, to help youth meet their goals during their transition into adulthood. CCSY is voluntary for the youth, but societies are required to provide these supports to eligible youth. All youth receiving supports through CCSY (financial or non-financial) must have a CCSY agreement. Agreements are renewed yearly until the youth’s 21st birthday and are up to 12 months in duration.
Deaths With Society/Agency Involvement – Customary care
Children and youth were counted as being in "Customary care" when they were the subject of a customary care agreement.
Chart 8: Children and youth deaths with and without Society/Agency involvement in 2021
- Total Ontario deaths ages 0-19: 1062
- Coroner investigation ages 0-19: 456
- Coroner investigation with no Society/Agency involvement
- Coroner investigations with Society/Agency involvement ages 0-22: 117
- In care: 11
- Not in care: 105
- CCSY or VYSA: 20
- In Customary care: 1
In 2021, there were 117 deaths of children and youth with Society/Agency involvement. At the time of their death, one child was in customary care and 11 children were in care. Of those not in care, 20 youth were receiving supports through the CCSY or VYSA program.
Children And youth in care – 2019 to 2021
Between 2019 and 2021 there were 28 deaths of children and youth in care of the Society/Agency, with 12 deaths in 2019, a decrease to 5 deaths in 2020, and then an increase to 11 deaths in 2021. Over the three years, the highest number of deaths for children in care were within the age group of 0 to 4 years. The most common manner of death was undetermined, followed by accident for all three years.
Children and youth on VYSA or CCSY agreement – 2019—2021
From 2019 to 2021, there has been an increase in the total number of reported/investigated deaths of youth with VYSA or CCSY agreements to receive financial or non-financial support. In 2019 there were five youth that were under these agreements at the time of their death, and this increased to 10 youth in 2020, and 20 youth in 2021.
Accident was the most common manner of death among the youth on VYSA or CCSY for all three years. In 2021, 75% of the accidental deaths among these youth were attributed to acute drug toxicity.
Deaths of Indigenous children and youth with Society/Agency involvement investigated by the Office of the Chief Coroner
The ability to undertake meaningful analysis of the deaths of Indigenous children and youth served by societies/agencies is affected by limited data available to the OCC. Coroners may not identify children and youth as Indigenous as they rely on the information available during their investigation (information sources include but are not limited to family members, community service providers and police). This affects the determination of the true number of Indigenous children and youth deaths that were investigated by the OCC. For the purposes of this analysis, children and youth are identified as Indigenous if they were involved with one of the 13 Indigenous Child and Well-being Agencies in Ontario. In addition, children were identified to be Indigenous if any non-Indigenous children’s aid society made note of their identity in any documents reported to CYDRA.
Summary statistics using available data have been provided; however, given the noted limitations, meaningful inferences cannot be made. The OCC and CYDRA anticipate that with the future changes to the child and youth death review model, the quality and availability of data relating to Indigenous children and youth will be enhanced to support analyses that may inform prevention strategies targeted to Indigenous children and youth.
Analysis – Indigenous children and youth
In 2019, the deaths of 37 children and youth between the ages of 0 and 22 were identified as Indigenous with Society/Agency involvement. There was a slight decrease in the following years, with 25 deaths in 2020 and 31 deaths in 2021.
Chart 9: Number of deaths of Indigenous children and youth with Society/Agency involvement by age group, 2019—2021
Chart 9 displays the number of deaths of Indigenous children and youth with Society/Agency involvement between 2019—2021 by age groups. The highest number of deaths were among children between 0 and 4 years over each of the years, with a slight increase in 2021. Between the age groups 5-9 years to 15-19 years, there is a slight decrease in number of deaths in 2021, but an increase in 2021 for the 20+ age group. The overall age distribution of deaths among Indigenous children and youth is similar to the distribution for all deaths with Society/Agency involvement regardless of Indigenous identity (chart 7).
Chart 9.1: Deaths of Indigenous children and youth with Society/Agency involvement by manner of death, 2019-2021
Please note two deaths from 2020 and one death from 2021 were not included in Chart 9.1. No manner of death had been determined as they were not investigated by the OCC.
In 2019, the most common manner of death was suicide, this accounted for 27% of the deaths among Indigenous children and youth with Society/Agency involvement. Percentage of deaths by suicide among this population decreased over the following two years. In 2020 and 2021 the most common manner of death was undetermined, followed by suicide in 2020, and accident in 2021.
Indigenous children and youth In-care, customary care, CCSY Or VYSA
In 2019 and 2020, 20% of all children in care were Indigenous at the time of their death. There were no children in customary care in 2019, but there was 1 child in customary care in 2020. In 2019, 20% of all youth receiving supports from CCSY were Indigenous, which decreased to 10% in 2020.
In 2021, 36% of all children in care were Indigenous and there was one child in customary care at the time of their death. Of all the youth receiving supports from CCSY, 20% were Indigenous.
Analysis of factors identified through case reviews
Through case reviews, CYDRA accesses information that, when tracked over time, may identify emerging trends. This knowledge can help contribute to understanding how services may be enhanced to improve the safety of children who are involved with the child welfare system. (Definitions which describe the criteria for these factors can be found in Appendix B).
In addition to the factors identified by CYDRA as part of the case review process, societies/agencies report on vulnerability factors associated with the child, youth or their family as part of their submission of the Child Fatality Case Summary Report. These vulnerability factors have similarities to the factors tracked by CYDRA. Neither the vulnerability factors nor the factors that are tracked through CYDRA case reviews are necessarily predictive of death; however, both sets of data are collected and help evaluate trends over time.
Recommendations
CYDRA offers recommendations to Societies, Agencies and others arising from review of the investigation materials and the different death review processes. The recommendations are aimed at the prevention of further deaths including suggestions for enhancement or change in practice and/or procedures that may inform improvement in service delivery and potentially impact child and youth safety and well-being. These recommendations are sent out with a request for response from the receiving organization, and responses are tracked by the CYDRA unit.
The following table lists the categories and themes:
| Category | Theme |
|---|---|
| Service Level Community Collaboration |
|
| Education/Training |
|
| Organizational-Focused |
|
| System Level Change |
|
| Assessment |
|
| Family Support |
|
| Youth Support |
|
| Systemic |
|
Recipient organizations
The reviews conducted by CYDRA have resulted in several recommendations on service level, systemic, and structural levels. The recipient organizations include, but are not limited to, the following:
- Children’s Aid Societies / Indigenous Child and Family Well-being Agencies
- Ministries (Education, Health, Solicitor General, and Children, Community and Social Services)
- Federal Government
- School Boards
- Hospitals
The following are examples of recommendations provided to outside organizations.
1. Education/Training with regards to Human Trafficking.
The Ontario Association of Children's Aid Societies (OACAS) to conduct a review of children's aid societies to determine whether:
- They have received training regarding the risks related to human trafficking for youth in residential placements and that the training is trauma-informed.
- They have included language regarding human trafficking in their protocols with police services.
2. An LDRT policy recommendation was made to affirm anti-racism and anti-oppressive practice within the education system:
All school boards to adopt a relational policy framework as a companion to ‘Promoting a Positive School Climate’. Several resources should be developed as a part of this work: A review of job descriptions for school administration and staff to include relational aspects as a core competency. As a result, job descriptions, starting with principal and vice-principal, should be examined and revised to explicitly detail a primary requirement for these professionals to build and foster relationships with and amongst students, above any other authoritarian or administrative requirement of the role. The relational framework should be accompanied by a practical resource that can be applied to the entire school, the classroom and/or to students, and that this be developed using an anti-oppression and anti-racism lens.