Executive summary

In the first six months of 2017, five young people died in residential placements. All of the young people were in the care of a Children’s Aid Society or Indigenous Child Wellbeing Society (Society), and all of them struggled with mental health challenges.

The public, stakeholders and the Office of the Chief Coroner (OCC) felt that further exploration was required to determine whether this might be representative of a spike or part of a trend. To determine the answers to these questions, the OCC undertook an analysis of the data available to understand how many young people in the same circumstances had died.

The OCC identified a group of 12 deaths of young people in the care of a Children’s Aid Society or Indigenous Child Wellbeing Society (Society) that occurred while they were in residential placements between January 1, 2014 and July 31, 2017^{footnote 1[1]}

To inform the investigation of the deaths and provide an opportunity for recommendations to prevent further deaths, the OCC established the Expert Panel on the Deaths of Children and Youth in Residential Placements (Panel). 

The Panel was tasked with:

• reviewing and assessing the services and supports provided to the 12 young people;
• identifying any commonalities and/or trends arising out of the review and assessment of the deaths;
• identifying any systemic issues or concerns arising out of the review and assessment of the deaths;
• providing expert opinion on the extent to which current and forthcoming plans, activities, legislation, regulations, policies and practices, including the activities outlined in Safe and Caring Places for Children and Youth: Ontario’s Blueprint for Building a New System of Licensed Residential Services and initiatives underway in the child welfare and children’s mental health sectors address any issues or concerns identified; and
• making recommendations that may assist in preventing further deaths.