Introduction

In Ontario, death investigation services are provided by the Office of the Chief Coroner (OCC) and the Ontario Forensic Pathology Service (OFPS). Together, they form a division within the Ministry of Community Safety and Correctional Services.

The OCC derives its mandate from the Coroners Act. Under the Act, coroners are responsible for undertaking investigations pursuant to the criteria set out in section 10 of the Act and in the public interest, to enable the coroner to answer specific questions about a death, determine whether or not an inquest is necessary, and to collect and analyze information about a death in order to prevent further deaths.

The extent of a death investigation can vary, depending on the circumstances surrounding the death. Should the OCC believe that there may be systemic issues that, if addressed, could help prevent further deaths, a special review may be completed.

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 that occurred while they were in residential placements between January 1, 2014 and July 31, 2017.^{footnote 1[1]} All of the young people had a history of mental health challenges.

A number of common issues were identified during a preliminary review of the 12 cases. The issues had been previously recognized by those involved with care in residential placements including, the Ministry of Children and Youth Services – which is now the Ministry of Children, Community and Social Services (MCCSS). Collectively, MCCSS, the Ontario Association of Children’s Aid Societies, the Association of Native Child and Family Service Agencies of Ontario and Children’s Mental Health Ontario were making efforts to address the challenges and identify, develop and help implement solutions to address current critical issues in residential services.^{footnote 2[2]}

The OCC established the Panel to inform the investigation of these 12 deaths and provide an opportunity for recommendations to prevent further deaths. The Panel was tasked with the following:

1. Review and assess the services and supports provided to the 12 young people;
2. Identify any commonalities and/or trends arising out of the review and assessment of the deaths;
3. Identify any systemic issues or concerns arising out of the review and assessment of the deaths;
4. Provide 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 activities underway in the child welfare and children’s mental health sectors address any issues or concerns identified;
5. Make recommendations to the Chief Coroner, if appropriate, with a view to effective intervention and prevention strategies toward the prevention of further deaths.

The review was intended to be specific to the services and supports provided to the 12 young people that are linked by the fact that their deaths occurred in residential placements. The Panel was permitted to review and discuss the suitability of the residential placements, availability of services, and issues of service quality and oversight mechanisms. In addition, the reviewers were also permitted to consider how the determinants of health, socio-economic circumstances and the intersections between systems of care may have impacted the outcomes of these young people.

Services and service systems that were not directly linked with those provided to the 12 young people were considered out of scope and beyond the mandate of the OCC.

The OCC did not wish to “reinvent the wheel,” and therefore the Panel’s terms of reference asked them to provide opinion on whether the current initiatives underway addressed any issues and concerns identified. The Panel also reviewed multiple other reports and reviews in the course of their formulation of recommendations; details on the reports reviewed can be found in the section titled Current Work Underway.