Monday, Tuesday, Wednesday….Building A New Child Death Review Process

What do we do when a child dies in Ontario? What do we do when that child has not survived our collective attempts to protect them?

Every three days on average a child dies who, within a 12 monthperiod, is somehow connected to our child protection system. Most of these children are still living with their families but the child protection system has involvement with them, some are living under the governments care at the time of their death. 

A child dies every three days; Monday, Tuesday, Wednesday a child dies, Thursday, Friday. Saturday a child dies…and on and on , every week, every year.  

What do we do?

Each of the deaths is reported to the Ministry of Community Children and Social Services (MCCSS) through a Serious Occurrence Report and is also reported to the Coroner.  The child protection agency involved does its own review of the service it offered and sends it to the Ministry. There is a Pediatric Death Review Committee  (PDRC) the responsibility of the Coroner.  The PDRC composed of a Coroner, child protection system representatives and at times a few others meets and reviews the deaths of a select group of children who died.  The PDRC looks at child protection practice and can make recommendations to agencies and the Ministry.  

The reports of the PDRC are not public nor are the recommendations of the report.

Once a year the Coroner will produce a PDRC report with a roll up of numbers related to the deaths reviewed. At times the report is delayed.  At times the PDRC is behind in its reviews.  Time is money.

I suppose it is not surprising that the child protection system which was created and is reformed in private, behind closed doors, by those deemed “experts” in their own activity also has a child death review system that is equally cloaked in privacy and secrecy.  It has never been an effective system of review.  It has never honoured the children who we have lost.

And then there are Inquests.  Unlike deaths that might occur in prison ,the deaths of children living in care, let alone connected to care, do not require an Inquest to be held.  There are simply too many deaths of children connected to child protection and Inquests are expensive. 

Not that Inquests are incredibly useful. They do provide a measure of accountability and they provide for transparency.  As young people have said “Inquests make us visible and it is when we are invisible that bad things happen”. The recommendations from Inquest juries go largely unheeded.  Yet Inquests are the tool we have to honour young lives lost and I believe we should use that tool.

All this to say that when I left the position as Ontario’s Provincial Advocate for Children and Youth I was challenged by the Coroner of the Province, Dr Dirk Huyer, to contribute to making things better .  He asked me to support his interest in developing a new model of child death review that in my mind would replace the moribund PDRC .  I was assured the process would NOT replace Inquests. 

Dr Huyer had conceptualized a process he termed “Local Death Review Tables” (LDRT) .  Instead of “reviewing” the deaths of children from inside a boardroom in downtown Toronto, the review process being led by the very system that would require change, Dr Huyer imagined a process that would be community based and would bring to the table all of the services and institutions that touched the life of the child who had died and that touched their family.  The goal of an LDRT to discuss honestly and courageously the manner in which the Provincemay have failed the child and their family.  

Dr Huyer is a compelling persuasive fellow.  There was no doubt that he cared about the children of Ontario.  I agreed to participate in the development of the LDRT process and the piloting of the process through five LDRT tables.   Of course, as is my want I had conditions.  I insisted that the LDRT process have a measure of “citizen participation”.  I do not think that services and institutions can effectively postulate and create change on their own.  I believe that any review of the death of a child, particularly at a local level must include the perspective and wisdom of their “family” however family may have been constituted.  I believe that young people , whose wisdom is powerful, should have their voice heard in any process,  I believe that there may be those in communities who hold a perspective that could be of assistance to any review process, ( cultural organizations, particular academics, advocacy groups).  I am pleased  to say that to at least a certain extent the voices of young people, the family, and “experts” were heard at the tables during pilots.

A position of “Amicus” or a friend to the process was created.  The Amicus will be at every LDRT.  They will be appointed in each region of the Province.  The role of the Amicus to ensure the voice of the family and young people are heard and to ensure tough questions are not avoided at any LDRT.  I was the guinea pig “Amicus” for all the pilot tables.  

I also insisted that the LDRT process be transparent.  I believe that transparency helps to spur change.  The LDRT process assumes no one involved in a child’s life wishes harm to children.  In my life’s journey this has been a safe assumption with very few exceptions.  This does not mean care givers, service providers, bureaucrats, legislators, may use poor judgement, lose sight of the child, make errors.  They do.  We do.  I felt that reports of each LDRT and the recommendations of the Coroner contained in the reports should be made public.  I felt that the Coroner should expect that responses to recommendations made to specific parties should be provided to the Coroner within a year they were made, and those responses should be made public.  The Coroner agreed to make the reports, recommendations and responses “available” to the public but will not post them on the Coroner’s site.  As well the Coroner decided that the restrictions imposed by privacy legislation would mean the reports would be required to be written without identifying the deceased.  This limit to transparency might be of concern to some including myself but I would state I understand it.  There are some families and communities who do not wish to endure the pain of reliving the death of their child in a public space.  They will have a copy of the reports and will choose what if anything they wish to do with them.  

At the same time I believe since the reports are not identifying and public documents they should be made public.  Maybe one day the Coroner will post them on his site.  In the meantime here are the reports from the pilot LDRT tables.  They have been given a virtual link by the Laidlaw Foundation of Ontario through my status as a “Laidlaw Fellow”. I am grateful to Laidlaw for this act of child advocacy.

http://laidlawfdn.org/uploads/CYDRA%20LDRT%20Final%20Report%202016-500%20R.pdf

http://laidlawfdn.org/uploads/CYDRA%20LDRT%20Final%20Report%202018-8165%20R.pdf

http://laidlawfdn.org/uploads/CYDRA%20LDRT%20Final%20Report%202018-11906%20R.pdf

http://laidlawfdn.org/uploads/CYDRA%20LDRT%20Final%20Report%202019-13147%20R.pdf

http://laidlawfdn.org/uploads/CYDRA%20LDRT%20Final%20Report%202019-13147%20R%5b1%5d.pdf

There is a good deal of work still left to do in developing this LDRT process.  There is a great team working within the Coroner’s Office honing the process.  My hope is that it will transform and change throughout the coming months and years, never remaining static.  I will continue to support the team in any way they deem appropriate.  

There is a need to identify a mechanism through which child protection agencies in Ontario can be held accountable.  As I have written and stated I do not believe the PDRC which still exists is this mechanism.  The LDRT is not designed for this task.  The Ombudsman perhaps might be invited to undertake this role. Im not sure.  I am certain however it is crucial.  Absolutely crucial. 

Monday, Tuesday, Wednesday a child dies…