Section 1: Records reviews

The twelve young people & their histories

All 12 young people were touched by complex and often intersecting experiences, starting at an early age. They had been removed from their families of origin and were in a placement at the time of their death, and all were high-risk. The majority of them had been removed from their home communities and were up to 1,600 kilometres from their homes of origin.

Many of the young people identified as LGBTQI2S. Eight of the young people were Indigenous. All of those young people were from First Nations communities in Northern Ontario, and the majority of those communities are remote. One of the young people was Black.

Many of these young people experienced mental health challenges, struggled with substance use, and had developmental challenges, features of fetal alcohol spectrum disorder and attachment disorders. All of the young people had histories that included self-injurious behaviors and/or suicidality.

Of the 12 young people, eight died by suicide; one by homicide; two were determined to be accidental; and one died of undetermined causes. A death is classified as undetermined when a full investigation has shown no evidence for any specific classification or there is equal evidence or a significant contest among two or more manners of death.

Danny

Danny^{footnote *[*]} was described as quiet and polite with a very good sense of humour. He was further described as an intelligent boy with some very significant learning disabilities in the areas of thought processing and memory.

At age six, Danny and his brothers were brought to Canada by their mother.

The Children’s Aid Society became involved when Danny at the age of eight years due to inappropriate behaviour at school and concerns that he may be subject to physical abuse. Over time, concerns about mental health issues within the family, poverty, uncertain immigration status and a lack of family and community supports arose. Danny was brought into the care of the society on an emergency basis at age nine. Two years later, Danny was the subject of an order for Crown wardship (now known as extended society care).

Shortly after his admission to care, Danny began self-harming and received in-patient assessment in three children’s mental health facilities. Over the next few years he was diagnosed as having an adjustment disorder with anxious features, possible attention deficit hyperactivity disorder and a learning disability. There was recognition of severe psychosocial stressors, academic difficulties and bullying. Danny required accommodations that were identified to be needed but were not provided for a long period of time. For example, he required eye glasses and a laptop for educational purposes – both were provided after a long delay. Medication was prescribed to address distorted thinking, perceptual distortion, sleep disturbance, fear and anxiety. Later in his life, Danny was diagnosed as having complex traumatic syndrome with severe features of anxiety and intermittent psychotic symptoms, a motor tic disorder, dysthymia and early signs of affective psychotic syndrome. It was noted that Danny’s learning disability would be a barrier for most therapeutic processes.

Danny lived in 10 placements in his six and a half years in care. Initially, Danny was placed with his brothers in his home community, in a foster care home operated by an agency. At Danny’s request, he moved to a group home without his brothers approximately a year later. He remained in this group home for three years, until his death.

For a period of time in Danny’s last placement, he attended a section 23 classroom,^{footnote 1[1]} where he reportedly did well academically. After progressing significantly, he was reintegrated into a community school for high school, where he did not appear to have been connected with school activities or staff.

The recommendations outlined in assessments for therapeutic intervention and a structured and supportive living environment were not identifiable in this placement. A request by the Society to connect Danny to community based mental health services did not occur and the reasons were not clearly documented.

As he aged, Danny became quieter and continued to be introverted with fewer outbursts of aggression or negative emotion. Over his final three years, Danny transitioned from being afraid to leave the group home and unwilling to participate in community activities to being generally absent from the group home and spending his time with friends in the community. Danny had minimal contact with the staff and there are no indications in the records that the staff was aware of how he was doing. In the year prior to his death, Danny chose to discontinue art therapy and refused all medication. As Danny did not engage in the type of behaviour that required an immediate response (for example, aggressing against staff), there were few reports of any incidents. Danny does not appear to have been engaged with staff in the last year of his life. In the months leading up to his death, Danny’s school attendance began to decrease.

On the morning of his death, at the age of 16, Danny went to his first class and then left the school. His body was found the next day in a park. The manner of death was found to be suicide by hanging.

Anaya

Described as an outgoing likeable child, Anaya^{footnote *[*]} was reported to have sought out opportunities to participate in her Indigenous culture, especially by dancing. She loved attending Pow Wows. She also enjoyed swimming and ice hockey as recreational activities.

Anaya was the youngest of four daughters born to her mother. All three of Anaya’s siblings were reported to struggle with addictions and mental health challenges. Approximately seven months apart, two of Anaya’s sisters died by suicide in the time immediately preceding Anaya’s death. No information is available about her father.

For the first few months of her life, Anaya and her sisters lived with their grandmother until she was no longer able to care for them. The Society had been involved with the family prior to Anaya’s birth and became re-involved at this point. Anaya lived with an aunt and her family from the time she was seven months old until she was nine years old under a customary care agreement. Anaya’s mother had sporadic contact with her children over the years, and it is reported that her mother stated that she did not wish to regain custody.

After eight years in this placement, Anaya disclosed physical abuse. The subsequent investigation did not verify the allegation. Nevertheless, Anaya moved to a nearby community and lived with her grandfather and one of her sisters under a customary care agreement. The allegation of abuse was later recanted by Anaya and she repeatedly asked the Society to return her to her aunt’s home.

Anaya remained with her grandfather and developed a close bond with him. The Society maintained involvement as there was documentation of concerns about the level of supervision in this placement. Offers of assistance to address this issue were declined. Anaya was continually left in the care of family members who were reported to be emotionally abusive. It was noted that mandatory standards related to visits and documentation were not followed in either of the customary care placements.

As a young child, Anaya was assessed as having an executive function disability and had significant cognitive delays. She was never formally diagnosed with fetal alcohol spectrum disorder or any other mental health condition, although this was suspected by health professionals. No medication for behavioural or mental health concerns was prescribed.

Anaya’s attendance at school appears to have been regular throughout her life. In the seven months prior to her death she was absent from school for 26.5 days.

Beginning at six years old, concerns were noted about Anaya’s precocious sexualized behaviour. Two years later, Anaya reported that she was using alcohol. She experienced at least two incidents of sexual abuse, and other instances were suspected. Anaya later became involved in solvent use and was reported to experience frequent and recurring episodes of suicidal ideation and self-harm. Concerns were raised by family members and school personnel and some sporadic counselling was provided to Anaya and her family.

At age 11, Anaya spent three weeks in an assessment home. Shortly thereafter, she spent 10 weeks in a residential treatment program designed for Indigenous youth. Anaya made attempts to die by suicide while in the residential treatment centre. The centre was noted to be designed for older youth whose cognitive abilities were greater than those of Anaya. Although efforts were made to modify the program to meet Anaya’s needs, it was reported that she was not able to understand the concept of treatment. Anaya left the program unexpectedly following the suicide of her second sister. A safety plan was developed and she was released into the care of her remaining sister to return to her grandfather’s home to grieve with the family. Three weeks later, Anaya sent a letter to a relative stating her intention to die by suicide. She had previously sent similar letters to friends. A few days later, Anaya left school to go to her grandfather’s home for lunch and did not return for the afternoon. Her body was found in the home later that day. The cause of death was hanging and the manner of death was suicide.

Jazmine

As a younger child, Jazmine^{footnote *[*]} was described as pleasant and polite. She did very well in school and was well-liked by her peers. Later on in her life little was documented about other aspects of her strengths or interests in her early life.

Jazmine lived in a Northern Ontario city with her biological parents and two younger brothers until her parents separated when she was nine years old. The Society became involved as a result of a concern that Jazmine was anxious and wanted to hurt herself. Instances of intimate partner violence and substance use were reported to have occurred in Jazmine’s family. The Society verified concerns about the caregiver’s ability to care for the children. At that time, Jazmine reportedly disclosed that she wanted to die by suicide.

Shortly afterward, Jazmine and her brothers went to live with their grandmother in the family’s remote First Nation community, located 500 kilometres away from the city that she had grown up in. Jazmine lived with her grandmother in a formal customary care arrangement from the time she was nine years old until her death. Two children’s aid societies were involved (responsive to the location of various family members) and family reunification was seen as a preferred outcome. There is minimal evidence of collaborative or coordinated planning for the children between the two societies.

Jazmine attended two schools without any apparent disruption in her education. She was reported to have done well at both schools.

Jazmine was first assessed by a mental health professional at age 10 as a result of self-harming behaviour and suicidal ideation. Referrals were made for expressive arts therapy and counselling, however, this support was sporadic due to the challenges of providing service in the remote community.

Jazmine continued to self-harm. At age 12, she was re-assessed. The assessment concluded Jazmine was experiencing a mood disorder and problems relating to abuse and neglect. The assessment strongly reinforced the need for collaborative planning and monitoring by the societies involved; the school and the family. Immediate and intensive intervention was indicated as necessary; however, it appears from the records that this did not occur. Records were incomplete and confusing, making it difficult to understand the supports provided.

Over the next seven months, some inconsistent and limited counselling was provided. Jazmine was not prescribed any medication. While she continued to exhibit signs of significant depression, she received no further help, despite documented concern that her needs seemed to be beyond her grandmother’s ability to cope.

On the night of her death at the age of 12, Jazmine visited with her grandmother and then had dinner at the home of other relatives. Later in the evening, Jazmine’s body was found by one of her siblings. The cause of death was hanging and the manner of death was determined to be suicide.

Tyra

Tyra was described as an excellent student and a committed athlete who was consistently noted as having a lot of potential. Her intention was to attend university away from her home community and she had identified an interest in working in the corrections field. She was described as having a big heart.

Early in her life, Tyra’s parents separated and she lived with her mother and two siblings. For a period, their mother’s new partner lived with them. Child protection concerns related to parental supervision and instances of the children being in the home during parties involving substance use, where adults unknown to them were present.

The Society was involved with the family during Tyra’s early years and verified that the children’s basic needs were not being met. Family support was provided in the home. When Tyra became an adolescent, she requested that she be taken into the care of the Society. She reported feeling depressed and had begun self-harming. Tyra disclosed that she was the victim of sexual abuse early in her life and that she experienced further victimization in adolescence. Her parents agreed to a temporary care agreement and she lived under the care of the Society for the rest of her life.

With the support of experienced foster parents, Tyra was provided with significant trauma-informed counselling and intensive support from her school community. Despite this, she continued to be unsettled. Approximately a year after coming into care, Tyra was admitted to the children’s psychiatric unit of the local hospital as a result of suicide ideation. She was diagnosed with depression and post-traumatic stress disorder and placed on medication.

A series of suicide attempts in the following months led to two additional in-patient admissions to the children’s psychiatric unit of a local hospital. A move to a residential treatment program operated by a children’s mental health centre was seen to be better able to respond to Tyra’s needs. While at the program she was able to stabilize and return to school. Tyra continued to self-harm, including multiple suicide attempts.

Tyra was reported to have been an excellent student throughout elementary school and high school. With the exception of time Tyra spent hospitalized in relation to her mental health, her school attendance was not interrupted.

Tyra was surrounded by a group of helping professionals from the Society, school and children’s mental health sector who maintained extremely close contact with her and communicated with one another on a very regular basis regarding her welfare.

On the day of her death at the age of 18, Tyra left school in the afternoon. Her body was later found hanging from a tree in a wooded area off a recreation trail. Tyra’s cause of death was hanging and the manner of death was suicide.

Justin

Justin was described as a sensitive and likeable young man who loved nature and particularly, fishing and walking in the forest. Justin enjoyed watching movies, playing board games and making arts and craft projects that he frequently gifted to others.

At two years of age, Justin was assessed by a paediatric development clinic due to concerns related to his inattention and behaviour. Early intervention services were subsequently provided. Over the course of his life, Justin was diagnosed as having a developmental disability and mental health challenges. Additionally, he was diagnosed with attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder, alcohol related neurodevelopmental disorder and significant learning disabilities. Justin was prescribed medication as a young child to respond to the ADHD symptoms, and additional medication in response to anxiety and escalating aggression was prescribed as he aged.

The Society became involved with the family prior to Justin’s birth and remained involved throughout his life. Justin lived with his mother, father and two older siblings for the first two years of his life, until his parents separated. He continued living with his mother until the age of eight, when his grandparents began caring for him in a kinship care arrangement following concerns that his needs were not being adequately met. There were reports of Justin’s escalating aggression towards peers and school personnel at this time.

After almost two years, this arrangement was no longer viable as his grandparents struggled to manage Justin’s increasingly challenging behaviour. Justin came into the care of the Society where he remained for the rest of his life. He lived in four different foster homes with each placement breaking down due to his escalating behaviour.

At age 10, Justin became a Crown ward (now known as extended society care) and just prior to his 12^th birthday, he moved to an unlicensed group home 550 kilometres from his home. Records indicate that an appropriate placement was not available closer to home. From this time, Justin lived in four different group homes before his fifth and final placement, where he lived until his death at age 17.

Due to an enrollment issue, Justin’s education was disrupted for a few months following a placement transfer. During this time, he was reportedly home schooled and attended a day treatment program on the premises of the group home.

It appears that minimal effort was made to provide mental health services or developmental services to Justin. Although he was going to transition to the adult developmental services sector, he had no contact with the developmental services agencies in the community.

At the time of his death, Justin was living in an unlicensed arrangement where staff supported him in his separate living unit within a triplex, with two other clients in separate units. Up to two staff supported him at a time.

Five days prior to his death at the age of 17, Justin was placed in a restraint following behavioral escalation that resulted from a disagreement with staff over whether he could ride his bicycle. Justin lost consciousness during the restraint. He was transported to hospital but did not regain consciousness and remained on life support. His cause of death was determined to be a result of Anoxic Encephalopathy due to Desmoglein-2 mutation-related cardiac arrest, with contributing factor of struggle/restraint. The manner of death was undetermined.

Azraya

Azraya was described as having a good sense of humour and an interest in fashion. She was one of three children born to her parents, an older brother and a twin brother. The family of five lived together throughout most of Azraya’s life in their Indigenous community in Northern Ontario, surrounded by grandparents and other relatives who were involved in the family’s life.

The Society was involved with the family prior to her birth and throughout most of her life as a result of concerns related to inadequate supervision, domestic violence and alcohol use. The Society provided some ongoing family supports and apprehended the children on several occasions.

Azraya’s parents struggled to provide care to the three children, including her older brother, who suffered from a progressive neurological disorder until the time of his death, when Azraya was twelve years of age.

Following her brother’s death, the family made arrangements for Azraya to move to a nearby city and live with a relative while she was attending school. Four months after her brother’s death, Azraya was admitted to the local hospital as a result of suicidal ideation. The Society sought and was granted a protection order, following which Azraya lived in a Society operated residence for a short time before returning to her parent’s home.

A few weeks later, Azraya was re-admitted to the adolescent psychiatric unit of the hospital following a suicide attempt. An assessment identified that little was known about Azraya’s early life, cognitive abilities or intellectual functioning that could impact on her ability to benefit from therapy. Following discharge, she was placed in three short-term placements while awaiting admission to a treatment foster home in Southern Ontario, where she subsequently lived for five months with 1:1 supervision.

Initially, it was reported that Azraya settled well into this placement however; following a visit from her family, her behaviour was reported to have become more challenging. Azraya expressed suicide ideation and was admitted to the psychiatric units of two local hospitals during this time. It was brought to the attention of the Society that the placement was unable to manage her behaviour, nor was the placement able to provide the supports and services that were thought to be in place.

While the Society began looking for an alternative placement, Azraya’s parents asserted their desire to bring her home. It was determined that she would go home under a supervision order with terms and conditions, which included attending mental health services.

For the next six months, Azraya lived primarily at home. During this time the environment was reported to be unstable. She came into care on a few occasions following incidents of substance use or violence when she would reach out to the Society and ask for intervention. It appears that Azraya was not receiving mental health supports at this time.

The Society had set up an intake appointment for a residential treatment program designed for Indigenous youth. The appointment did not occur as Azraya died prior to the appointment date. Two weeks before her death, she indicated that she wished to come back into the care of the Society due to escalating challenges at home. On a temporary basis, Azraya was placed in a Society operated home, where she was housed in an apartment (without other young people) and supported by casual, relief staff. Azraya was known to be at high risk of self-harm and had constant supervision by a 1:1 worker. This was discontinued in the days prior to her death. No rationale for discontinuing the 1:1 supervision was found in the documentation reviewed.

Azraya did not attend school for the last year of her life. During this time she was hospitalized, in treatment foster care, in Society operated homes for short periods, or in the care of her parents under a supervision order. In the four months she was in treatment foster care, she was registered in two different schools, but only attended school for one day.

On the night of her death at the age of 14, Azraya missed her curfew and was known to be attending a house party. The police attended the party and brought her to the emergency department of the local hospital. The staff of the society operated home attended the hospital at which point the police left. A short time later, Azraya left the hospital and a search was immediately launched. Two days later, she was found in a forest adjacent to the hospital. The cause of death was hanging and the manner of death was suicide.

Kanina

From an early age Kanina was described as active socially and physically. She enjoyed school, particularly math and science. Kanina provided support to her older sister and was called Kookooomes by one of her foster parents.

Kanina was a young person from a remote First Nation. She lived with her biological parents and five siblings until she and her sister came into care under a customary care agreement when Kanina was two years of age. She was admitted to care ten times over the course of her life, generally for six month periods. The goal of family reunification remained throughout her time in care. Instances of intimate partner violence and substance use were reported to have occurred in the family home throughout Kanina’s life. There was a significant history of deaths by suicide in Kanina’s family. Her parents twice successfully completed family treatment programs, which included some or all of the children.

Kanina was referred for counselling at the age of seven following the death of her aunt by suicide. Counselling at that time and in the months prior to her death at age 15, focused on her grief at the loss of relationships. Kanina did not receive a psychiatric diagnosis and was not on any medication.

In the final year of her life, Kanina had a number of placement changes, which often followed incidents of self-harm, suicidal ideation and attempts. Following a placement transfer, Kanina was not attending school for a period of time. From the documentation, it is unclear what the reason for this disruption in her education was, or how long she was not attending school.

In the four months prior to her death she was placed in an Indigenous youth healing centre. She was medically evacuated out twice in response to self-harming behaviour and suicide attempts. The most recent visit to hospital occurred five days prior to her death.

While residing in the healing centre, Kanina began a relationship with another female resident. This female resident, Jolynn, is also the subject of review by the Panel. In the weeks and days prior to her death, the two were together on a number of occasions. Although this relationship is referred to in various documents, there was no evidence of supportive discussions around Kanina’s sexual identity. Additionally, it appears that staff indicated to her that she could be arrested for engaging in a sexual relationship with Jolynn, as a result of Jolynn’s age. While this is accurate from a legal perspective, this position does not demonstrate responsiveness or recognition of the needs Kanina was endeavouring to meet.

Kanina was in her final placement for less than three days prior to her death. The placement was a staff-model foster home operated by the Indigenous Child Wellbeing Society.

At the age of 15, Kanina died by suicide at her foster home. She recorded her suicide on her iPad. Suicide notes were left for various family members and Jolynn. The autopsy indicated significant evidence of self-harm over time on various parts of Kanina’s body.

Jolynn

Jolynn was an Indigenous young person born in Northern Ontario. She was described as quiet. She liked to draw and sketch.

Jolynn lived with her biological mother prior to her admission to care at two years of age. Her mother had a history of transience and substance use reported to have occurred during Jolynn’s early years. Her biological father was not known to her until the last year of her life.

Shortly after her admission to care, Jolynn was placed in a customary care home operated by the Indigenous Child Wellbeing Society. After seven years in this placement, Jolynn was discharged from the care of the society into the care of the same caregiver, through a private arrangement. She remained with this caregiver and their family until the age of eleven.

Following the breakdown of this placement, Jolynn had 20 placements in an 18 month period. Placement changes often occurred on an unplanned basis following a behavioural incident. Jolynn’s education was described in a social history in her file as “interrupted” by multiple placement changes. During some placements, she was not enrolled in school. The last grade Jolynn completed was grade six – she would have been in grade seven, had she been enrolled at the time of her death.

In the six months prior to her death, Jolynn was placed at a youth healing centre on two occasions. While at the centre, Jolynn began a relationship with another female resident. This resident, Kanina, is also the subject of review by the Panel. Kanina left the centre and Jolynn was later medically evacuated from the centre following a suicide attempt. While away from the healing centre, in the days prior to Kanina’s death the two were together on a number of occasions. Within days, Jolynn learned that Kanina had died by suicide.

Following this, Jolynn was admitted to the child and adolescent mental health unit of a hospital for 17 days. Except for a period of time during this hospital admission, Jolynn was not prescribed any medication at any point in her life.

While placed in the hospital, Jolynn spoke to staff about her relationship with Kanina and her feelings about this loss. There were no records suggesting that Jolynn’s sexual identity was ever discussed with her while in hospital or by staff of other organizations including the Indigenous Child Wellbeing Society.

On discharge from hospital, no children’s mental health treatment bed was available. Consequently, Jolynn was discharged to an extended home visit at her father’s home pending the availability of a treatment bed. A safety plan was agreed to by the hospital, the Indigenous Child Wellbeing Society, the family and Jolynn. There was, however, no evidence of active therapeutic intervention during the seven weeks she was in her father’s home.

At the age of 12, Jolynn died by suicide in her father’s home. Kanina’s death by suicide is felt to have been an influencing factor in Jolynn’s suicide. The autopsy indicated significant evidence of self-harm on various parts of Jolynn’s body.

Kassandra

Kassandra was described as an intelligent, energetic and pleasant youth who loved to dance, sing and do gymnastics.

Kassandra lived with her biological parents and one older brother until her admission to care at age 12. Instances of intimate partner violence and substance use were reported to have occurred during her early years.

Over the course of her life, Kassandra was diagnosed with attention deficit hyperactivity disorder (ADHD), mood dysregulation disorder, and generalized anxiety disorder. She was on various medications beginning at age 11 and continuing until the time of her death at age 14, including, at various times, stimulant medication for ADHD, antipsychotics and antidepressants.

Kassandra’s behavior was reportedly challenging from very early in her life. Reports outline increasing instances of violence, aggression and behavioral disturbances between age two and age seven. At age seven, the Society became involved on an ongoing basis and in-home family intervention was put in place along with access to a parenting program. Kassandra’s mother is reported to have requested assistance on multiple occasions, but was unable to obtain the type of help she felt was necessary to cope with her daughter’s behaviour.

At age seven, Kassandra’s mother requested her to be placed in a residential treatment facility. Community service providers were not in agreement and placement did not occur. Children’s mental health services were initiated and a period of tenuous stability in the home was noted. As Kassandra aged, there were repeated incidents requiring crisis intervention of police and hospital based mental health services. Kassandra’s behaviour was noted to have interfered with her ability to attend and succeed at school. At age 13, Kassandra moved to the first of four section 23 classrooms operated by residential providers or community agencies under a provision of the Education Act. Just before her 12th birthday, Kassandra was admitted to residential treatment. In the two and a half years between her admission to residential care and her death, Kassandra lived in seven different placements, with six months being the longest period in any one home. Her service providers were working toward a goal of family reunification; efforts were made to continue family therapy and Kassandra continued to have regular access to her family. In 2014, Kassandra came into extended society care with continued access with her mother.

Some mental health services were provided while Kassandra was in residential care, but she continued to struggle to benefit from these services. She was noted to have difficulty engaging with peers, staff or family in positive ways. Kassandra was self-harming and was placed in vulnerable situations with people she met over social media.

Kassandra was in her final placement for four months prior to her death. The placement was a staff-model foster home with two other residents. Available records did not provide details of the circumstances or needs of the other young people in the home; however, there are indications that the needs of the residents varied considerably and questions arose regarding the capacity of staff to meet the wide range of needs present in the home.

At the age of 14, Kassandra died from smoke inhalation in a fire at her foster home. The manner of death was determined by the coroner to be a homicide. The incident was precipitated by escalating behavior of another young person in the home, in response to which Kassandra and two staff removed themselves and locked themselves in a second-floor bedroom. A fire began on the first floor and they were unable to exit. Resuscitation attempts were unsuccessful.

Amy

Amy was described as a friendly but cautious person. She took pride in her appearance and showed interest in her Indigenous community and culture. When given the opportunity, she enjoyed learning birch bark construction and beading using traditional designs and methods. She liked to sketch and journal, and was interested in gymnastics.

The Society was involved with Amy’s family prior to her birth and throughout most of her life as a result of concerns related to inadequate supervision, parental substance use, domestic violence and one parent’s mental health. Amy and her siblings were apprehended by the Society on many occasions but returned shortly thereafter to the family with safety plans developed. The Panel identified more than eight referrals regarding child protection concerns in Amy’s family throughout her life. Over time the Society continued to respond to a very high volume of protection concerns and placements became more difficult to arrange.

Amy began engaging in high risk behaviour (cutting, as well as solvent and alcohol use) very early in her life. Amy witnessed family violence, suicide attempts and deaths in the community. She disclosed repeated instances of sexual assault that were reported to occur throughout her childhood.

Amy remained close to her sisters and was at times placed with them in foster care. Amy and one sister were part of a suicide pact with other youth, and there were multiple incidents of self-harm involving Amy and her sister. On many occasions, Amy was medically evacuated out of the community for medical attention following significant instances of self-harm.

Amy did not receive a formal assessment of her needs until near the end of her life. Prior to this, she primarily received mental health supports on an emergency basis following instances of self-harm and suicide attempts. Although fetal alcohol spectrum disorder was suspected, further investigation was not done. She was formally diagnosed with an adjustment disorder and Depression just prior to her death. Counselling was sporadic throughout her life, without the benefit of a consistent therapist or a coordinated approach.

From an early age, Amy did not attend school regularly. While she was in care there were periods of time where her attendance was more regular and she did well in school. However, during her last placement she was not enrolled in school due to administrative delays in retrieving documents from her previous placement.

At age 10, Amy came into the care of the Society and remained in their care for 15 months. Initially, she was placed in four short term foster homes and then moved to a residential program in Southern Ontario where she remained for 12 months prior to returning to her parent’s care. Amy returned home, where her behaviour escalated to include significant vandalism, alcohol and solvent use, suicide attempts and property damage that resulted in her being removed from the community and coming back into the care of the Society.

Amy was re-admitted to the same residential program. At the time of her return, the local Society was in the process of an institutional protection investigation of the children’s residence, which resulted in verification of several child protection concerns. Amy remained in the home following the investigation. After three months, Amy was involved in an altercation with staff and was immediately moved to another residential program nearby.

While in the new residential program, Amy continued to struggle with self-harm and aggressive behaviour that lead to hospitalizations and physical restraints. Amy was seeing a crisis counsellor at a community agency, however, it did not appear that this was a regular occurrence. It was known that Amy was part of a suicide pact, and two other youth in this pact had died by suicide. Amy also disclosed a past history of sexual abuse, as well as a more recent incident of sexual assault that was reported to have occurred during one of the times she left the residence without permission and was missing overnight.

As a result of self-harm, Amy was seen in urgent care and the emergency department of the local hospital on multiple occasions in the six months leading up to her death. Amy was admitted to hospital on two occasions, the last being for four days, approximately two weeks before her death. From her discharge to the day of her death, she was brought to the emergency department on three additional occasions related to self-harm and suicide ideation or attempt.

On the day of Amy’s death at the age of 13, staff at the residential program checked on her regularly as she was in her bedroom alone. Twenty minutes after the previous check, staff returned to her room with a snack for her and found her hanging by the cord from the window blind. Resuscitation attempts were unsuccessful. The cause of death was hanging and the manner of death was suicide.

Brooklyn

Brooklyn^{footnote *[*]} was described as a polite and friendly young person. She was of Indigenous heritage and was reported to enjoy participating in ceremonies and learning about her culture. She enjoyed a variety of sports. She enjoyed horseback riding, art, cooking and gardening.

Brooklyn lived with her parents for the first year of her life and for another period of eight months as a young child. She had five siblings and her early years reflect the challenges faced by her First Nation community including, poverty, substance use, minimal community supports and intermittent access to education. Brooklyn was apprehended at just under a year old. She maintained some contact with her parents and siblings on and off throughout her life. Brooklyn was consistently placed in the same home as her younger sister and they maintained a lifelong connection.

Brooklyn was diagnosed with fetal alcohol spectrum disorder, a mild developmental disability, a reactive attachment disorder, learning disabilities and developmental trauma disorder. As early as age four, a psychiatric assessment stressed the importance of permanency planning and warned of issues with attachment. Medication was prescribed to address symptoms of sleep disruption, attention, impulsivity and anger management. Brooklyn was twice admitted to in-patient children’s mental health units as a young adolescent, following outbursts of aggression, and received some counselling and art therapy while in her placements.

Efforts to find a stable kin or customary care living arrangement for Brooklyn closer to home were attempted throughout her life, but were unsuccessful. By the age of six, she had lived in 17 foster homes in Northern Ontario, almost all of which were located in First Nations communities.

At age six, Brooklyn and her sister moved to a foster home 800 kilometers from home, which was operated by an outside paid resource agency. Brooklyn had minimal English language skills at that time and had not attended school regularly. She and her younger sister lived with this foster family for six years, and this was by far the most permanency she experienced. The end of this foster placement was abrupt and the reasons appear to be unrelated to the children. Minimal support was provided to Brooklyn to process her feelings about this transition and the resulting change of foster parents, community, school and therapists.

Following two foster placements within the next year operated by a different outside paid resource agency, Brooklyn experienced eight additional placements operated by multiple OPR agencies between the ages of 13 and her death three years later. The longest duration of stay was seven months in one group home. From the age of 14, school attendance was disrupted and Brooklyn exhibited challenging behaviours that were anticipated in early assessments. Brooklyn had a history of fire setting behavior.

At the time of her death, Brooklyn had been living in a staff model foster home for ten weeks following an emergency placement with minimal transition planning. Brooklyn was not attending school nor was she involved in any community activities.

Following a series of departures from the group home without permission to meet individuals thought to be involved with illegal activities that took advantage of vulnerable youth, a screw was inserted into Brooklyn’s bedroom window to prevent it from opening fully. This occurred with the intention of preventing Brooklyn from using the window to depart the residence. No other safeguards and supports intended to mitigate the various concerns were evident.

Attempts to limit access to social media created significant contention, and Brooklyn would isolate herself in her bedroom, at times barricading herself in the room by pushing furniture against the door. On the day of her death at the age of 16, she became upset with staff when her internet access was withdrawn. She pushed her mattress against her bedroom door and set fire to it. The mattress blocked her exit and prevented staff from entering the room, as did the screw in the window. Her death was determined to be accidental as a result of smoke inhalation.

Ashley

Ashley^{footnote *[*]} was described as a bright young person who had musical talent. She expressed her creativity through sketching and drawing and liked to play cards and electronic games. She was known to have had remarkably good insight into the issues she experienced in her life, and had detailed discussions with physicians and psychiatrists about the effects that prescribed medications had on her.

When Ashley was abandoned at birth, her grandmother became her caregiver through an informal arrangement. They lived together for the next fifteen years in their First Nation community and her mother would visit sporadically.

As a child and young adolescent, Ashley witnessed domestic violence between extended family members and suicide attempts within the family. She experienced sexual abuse and bullying. Ashley engaged in substance use and vandalized communal property. She witnessed at least two incidents resulting in death or serious injury of another child in her early life.

Ashley’s frequent suicide attempts resulted in repeated medical evacuation to the children’s in-patient psychiatric unit of a local hospital. Her grandmother’s ability to care for Ashley became compromised as a result of her advancing age, challenging life circumstances and her own medical and mental health challenges.

At age 15, following eight instances of suicidal ideation and attempts, Ashley was brought into care under a customary care agreement and the Indigenous Child Wellbeing Society. This supported Ashley’s wish to enter a residential treatment program. Following this, her extensive background of psychiatric, psychological and behavioural problems resulted in six hospitalizations (two of which were approximately five months in duration) and 10 suicide attempts. She lived in 18 different placements, including treatment foster programs, three treatment programs operated by First Nations communities in Northern Ontario and on one occasion, secure treatment. Ashley moved 23 times, including four instances when she returned to her grandmother’s home when no alternative was available and five one-night placements on a crisis basis.

Over time, diagnoses included cannabis abuse, conduct disorder, post-traumatic stress disorder (PTSD), dissociative identity disorder, and complex trauma response including dissociation, intrusive recall and borderline organization. Ashley was reported to have used cannabis daily since the age of 11. Medication was prescribed and frequently adjusted as the efficacy of these medications was seen to be questionable. In particular, medication was used to prohibit the nighttime recall associated with the PTSD.

The possibility that Ashley was transgender was noted in the file but not addressed directly by any service provider.

Two months prior to her death, Ashley moved to a therapeutic foster program located close to her home community. At the time of her placement, an institutional child protection investigation of the children’s residence was underway and verified a number of child protection concerns.

Although Ashley was to have 1:1 staff supervision while in this placement, she was regularly allowed to leave the home unaccompanied by staff. She was not attending school or receiving any therapeutic intervention. Despite this, her behaviour seemed to stabilize and there were no suicide attempts while in this placement.

The evening preceding Ashley’s death, she was dropped off by staff of the foster home at a location where relatives from her home community were staying. Ashley was expected back at the foster home by 11 p.m. Ashley and three other young people went to a secluded area of a local park. The youth later confirmed that they had consumed alcohol, smoked marijuana and left Ashley in the park as she was unable to be roused.

When Ashley had not arrived at the foster home by 12:30 a.m., police were called and a missing person was reported. Ashley’s body was found in the park at approximately 8 p.m. that evening. It was determined that the death was accidental and the result of drowning in a young person with acute ethanol intoxication.