Dear Dr. Huyer,

We thank you for the opportunity to participate in this very important initiative, and we would like to take the opportunity to share our findings with you.

The Panel found that in the twelve cases of young people that were reviewed, the systems that were involved repeatedly failed in their collective responsibility to meet the fundamental needs of the young people. While no one individual or organization is at fault for these failures, it is important to recognize that it is people that make organizations and systems work – and people that define how they must work.

The young people that were the subject of the Panel’s review were in the care of Children’s Aid Societies or Indigenous Wellbeing Societies, and they were placed in various environments, including environments referred to as group homes, parent-model foster homes, staff-model foster homes, agency operated homes, residential treatment facilities and foster care treatment homes. They all struggled with developmental and/or mental health challenges. Collectively, they represent a cross-section of the most vulnerable, high risk young people in Ontario.

Ontario’s Safety Assessment is a tool used by child protection agencies to determine the level of immediate danger to a child. It considers the immediate threat of harm and the seriousness of the harm or danger given the current information and circumstances. Where imminent danger of harm to a child is present, the process considers which interventions are needed to mitigate the threat to the child. There are three outcomes to this assessment: safe, unsafe, and safe with intervention. The Panel was struck by the frequency with which the young people reviewed were found to be safe with intervention – in the absolute absence of any constructive intervention. None of these young people were safe, in their homes of origin or in most of, and in particular their final, placements. Child protection agencies seemed to be overwhelmingly concerned with immediate risk and more often than not failed to address longer term risks, which the Panel often felt were both predictable and preventable.

The Panel observed responses to challenges experienced by the young people and their families to be primarily crisis driven and reactionary. Often times, young people were identified as safe with intervention following a mental health crisis (e.g. self-harming behaviour, suicide attempt or ideation). The Panel found that in practice ‘safe’ often translated to a bed to sleep in and ‘intervention’ translated to 1:1 supervision – actions that are merely a postponement until the next crisis rather than providing meaningful supports to parents and young people that may have addressed issues and/or prevented future challenges.

As a society, we owe a duty of care to these young people; a duty of care that we suggest cannot be met by the system in its current state, despite the existence of well-intentioned workers and caregivers and the desire of many to do good work. We believe that in order to meet their needs, a reorientation of the service system – including all services to young people, their families and communities – is necessary. Ontario’s current system is largely reactive, operates in siloes, and focuses on services to the individual rather than the individual and their families and communities. Ontario’s most vulnerable young people, those with multiple needs in complex environments, need a system that is intentionally designed to provide wholistic, early, ongoing and prevention-focused care and treatment that works for them, their families and their communities – and they need it now.

We believe that with intention and commitment to a core set of principles and the implementation of some targeted recommendations, change is possible. The principles we have outlined are not new; they have been asserted, endorsed and recommended by governments, service organizations, advocacy organizations, panels, commissions and bodies many times over the last 25 years, and reflect best practices. We recognize that over time changes have been made to honour them – but the Panel asserts that it has not been enough.

The attached principles arose through our discussions as essential guideposts. We believe that dedication to implementing the concepts and philosophies below in policy and in practice will lead to a wholistic system that improves outcomes for Ontario’s most vulnerable people – those at highest risk, and in greatest need.

The recommendations have been developed with a view to practical and implementable changes that would make a fundamental difference to Ontario’s young people – both now, and over the longer-term. While there is some work happening, we are in agreement that it is not nearly enough – and not nearly soon enough – to effectively safeguard the young people in Ontario’s care.

Change is necessary, and the need is urgent. We ask that those in positions of power and influence, who are responsible for the functioning of the systems, be accountable for fixing them; that they take the lessons learned from the deaths of these young people and utilize them to ensure meaningful change. To that end, we ask you to use your power and influence to ensure that these recommendations do not go ignored, and that those in positions to make change are accountable to the public, and to young people, for their actions in response to these recommendations.

Once again, thank you for the opportunity.

Signed,

The Expert Panel on the Deaths of Children and Youth in Residential Placements:

Ms. Helen Cromarty
Ms. Sherry Copenace
Dr. Aryeh Gitterman
Ms. Joanne Lowe
Dr. Nathan Scharf
Ms. Stella Schimmens
Dr. Kim Snow