Process

The Panel were provided with a summary and analysis of the services and supports that were provided to the 12 young people. The summaries were developed based on information contained in the records of various service organizations, including societies, children’s mental health agencies, health professionals including mental health professionals and institutions, educational institutions and youth justice records. In addition, the case reviewer examined the coroners’ reports, post mortem reports and toxicology reports (where available).

Materials were requested from several organizations to help clarify current and forthcoming relevant policies and practices. Presenters with knowledge of the current system challenges and work underway appeared before the Panel to share information, insights and expertise. 

In addition, nine of the 12 families and leadership from four Indigenous First Nation communities provided information to the panel for consideration. Their input was vital in providing the Panel with insight into the experiences of the young people, their families and their communities. We thank each person that participated in this way for sharing their thoughts and for helping us to honour the deaths of these young people. Their insights have been woven into the fabric of this report and greatly enriched the Panel’s considerations. 

The insights of those living and working within the system were also sought and obtained.  Thirteen young people with lived experience were brought together in Kenora, Thunder Bay and Toronto. Staff of the OCC inquired about their placement histories and experiences of mental health care, and provided summaries of the information they shared to the Panel. The histories of the 12 young people that died and their thoughts, stories and suggestions were at the heart of the Panel’s work and provided the lens through which the Panel’s work found focus.

Throughout this report, where young people with lived experience transmitted messages relating to the findings and observations of the Panel or made suggestions to improve the experiences of young people, they are highlighted in purple. We have highlighted their input in order to elevate their voices; their messages speak volumes, and deserve to be heard.

In addition to meeting with young people with lived experience, staff of the OCC invited staff from the Children’s Aid and Indigenous Child Wellbeing Societies and placement settings that had worked with the 12 young people directly to share their insights into the systems of care. Ten staff chose to participate in this process. The names of the young people and staff that participated will not be released in the interests of protecting their privacy.

Over 100,000 pages of records were reviewed and the Panel received almost 4,000 pages of summary information. While the review of records is no substitute for speaking with service users, the depth of the information available to the Panel provided sufficient information to help them understand the young peoples’ varied experiences and trajectories.

Summaries of the individual experiences of the 12 young people comprise the first section of this report. Where the Panel had specific observations relating to the young person, they have been noted. The second section of the report outlines the Panel’s aggregate findings and observations in four areas of focus that emerged during their discussions:

• Society Involvement and Placements
• Mental Health Care
• Service Systems and
• System Oversight

The third section of the report outlines a set of principles and recommendations for change.

A note on wholistic care

Wholistic care is defined by the Oxford dictionary as a philosophy characterized by the belief that the parts of something are intimately interconnected and explicable only by reference to the whole.^{footnote 1[1]}

This philosophy was introduced to the Panel by its three Indigenous Elder members who put forward the notion that all services should be provided in ways that address the continuous interaction of the physical, mental, emotional and spiritual aspects of individuals.

While this concept is age-old in Indigenous communities, it is not widely embraced in Ontario’s westernized system of care. The Panel’s observation was that this philosophy is of benefit to all people. Consequently, it is a philosophy that underpins all of the Panel’s observations and recommendations.