Joint Directive: Ministry of Children and Youth Services
Ministry of Community and Social Services
Office of the Chief Coroner for the Province of Ontario



Child Death Reporting and Review

Effective Date: March 31, 2006

Introduction

This Directive is issued under section 20.1 of the Child and Family Services Act and replaces the October 1, 2000 Joint Directive on Child Death Reporting and Review.

The first and foremost function of a Society under the Child and Family Services Act is to protect children. As a result, when any child dies who was receiving service from a Society at the time of his or her death or at any time in the 12 months immediately prior to his or her death, there are extensive reporting requirements. In addition, when the child dies under questionable circumstances and/or as a result of abuse, mistreatment or parental negligence/neglect, the Ministry of Children and Youth Services requires the Society to conduct a full review of the case.

On an exceptional basis, the Society, in consultation with the Ministry of Children and Youth Services and the Office of the Chief Coroner, will conduct a review of other eases. In addition, the Office of the Chief Coroner's Paediatric Death Review Committee may review other cases as appropriate.

This Directive is the result of a comprehensive review conducted by the Ontario Ministry of Children and Youth Services, the Office of the Chief Coroner for the Province of Ontario and the Ontario Association of Children's Aid Societies regarding existing procedures for child death reporting and review. While each system has unique roles and responsibilities, this Directive demonstrates a mutual commitment to cross-sector co-ordination and collaboration. The Office of the Chief Coroner continues to be available on an ongoing basis to Societies and the Ministry of Children and Youth Services for consultation.

This Directive supplements the ministry's Serious Occurrence Reporting Procedures which include the requirement to report all deaths of clients that occur while participating in a service and the ministry's Enhanced Serious Occurrence Reporting Procedures which are to be followed when a significant incident results in the involvement of emergency services and/or where there is, or is likely to be, significant public or media attention.

Effective immediately, the Office of the Chief Coroner has lead responsibility for the analysis of child death, the dissemination of findings and recommendations related to child death and the production of an Annual Report on child death in Ontario. Mechanisms have been established within the ministry and in coordination with the Office of the Chief Coroner to ensure that relevant recommendations inform ministry policy development on a timely and ongoing basis.

The Annual Report will be the subject of review and consultation at an annual forum on child deaths to be undertaken by the ministry and the Office of the Chief Coroner, with the participation of Societies through the Ontario Association of Children's Aid Societies and the Association of Native Child and Family Services Agencies in Ontario.

A public report card on child deaths will be established and released jointly by the ministry and the Office of the Chief Coroner.

Notes and Definitions

This Directive describes requirements that apply when:

  1. A child who was receiving service from a Society at the time of their death, dies, or
  2. A child who received service from a Society at any time in the 12 months prior to their death, dies.

For the purposes of this Directive, a "child who received service from a Society" is a child who is receiving or received service directly from the Society, and/or a child who is receiving service indirectly through services provided to his or her family.

In all cases where information from the Society's initial notification or preliminary inquiry suggests that some form of immediate action by the ministry or the Society is necessary, such action should not be delayed pending the outcome of any review.

In Ontario, the coroner classifies deaths into five categories as follows:

  1. Natural: Death that is due to a natural disease, or a complication of a disease, or its treatment.
  2. Accidental: Death that is due to an occurrence, incident or event that happens without foresight or expectation.
  3. Homicide: Death that is due to the action of one human being killing another human being.
  4. Suicide: Death that is due to an intentional act of a person knowing the probable consequence of what he/she is about to do.
  5. Undetermined: Inadequate evidence for classification; equal evidence, or a significant contest for two or more classifications; suicide which does not meet higher standard of proof.

For the purposes of this Directive, cases will be considered questionable as follows:

Death classification Cases to be considered questionable
Natural
  • All cases (in care, at home or open) if there are any grounds to suspect that the death was contributed to or linked to an act of omission or commission on the part of caregiver
Accident
Homicide
Suicide
  • All cases where the child was in care
  • All other cases (open or closed) if the circumstances surrounding the child's death relate in any way to the reasons for service and or Society involvement
Undetermined
  • All cases

Requirements

  1. The Society will notify the local coroner and the ministry's Regional Office immediately whenever they have knowledge that: (A) a child who received service from the Society up to the time of his or her death, dies, or (B) a child who received service from the Society at any time in the 12 months prior to his or her death, dies.
  2. The Society will complete a Serious Occurrence Report as set out in the ministry's Serious Occurrence Reporting Procedures. The Society will immediately forward copies of the report to the Regional Office, the Regional Supervising Coroner and the Deputy Chief Coroner (or delegate). In addition, the Society will follow the ministry's Enhanced Serious Occurrence Reporting Procedures when appropriate.
  3. The Regional Office will review the Serious Occurrence Report provided and file a Contentious issue Report (CI) according to ministry procedures. Even if a child's death may not appear to be contentious it is deemed as such for purposes of this Directive. The CI should summarize the case, ensuring no client identifying information is provided, and detail the action being taken by the Society and the Regional Office. (If information is incomplete at the time of the initial notification or preliminary inquiry, the Regional Office should indicate this, and clarify through CI up-dates as information becomes more readily available).
  4. The Society will complete a case summary (using the Child Fatality Case Summary Report template). The Society may contact the Office of the Chief Coroner directly for information regarding the cause of death. The case summary will include the Society's determination as to whether the child died under questionable circumstances and/or as a result of abuse, mistreatment or parental negligence/neglect. Within 14 days of the child's death or within 14 days of learning that the child bas died, the Society will forward copies of the report to the Regional Office and to the Chair of the Paediatric Death Review Committee.
  5. The Chair of the Paediatric Death Review Committee will review the Child Fatality Case Summary Report, and will decide within seven days of receiving the report whether the Society must undertake an Internal Child Death Review. The Chair will notify the Society of this decision in writing and will provide a copy of this correspondence to the Regional Office.
  6. If the Chair of the Paediatric Death Review Committee determines that an Internal Child Death Review is required, then the Society will conduct a full review of the case. The Society will establish a review team and will include an external reviewer with appropriate clinical expertise on the team.
  7. The Society will complete a full Internal Child Death Review within 90 days of the decision made by the Chair of the Paediatric Death Review Committee, the Society will forward copies of the report to the Regional Office and to the Chair of the Paediatric Death Review Committee.
  8. The Society will submit written progress reports every six months to the Regional Office when the Internal Child Death Review includes recommendations for further action or follow-up by the Society.
  9. Based on the Society's Internal Child Death Review, the Office of the Chief Coroner will determine whether the Paediatric Death Review Committee will undertake a further review, and if so, how detailed a review it will be.
  10. If the Paediatric Death Review Committee conducts a review, the Committee will complete the review within one year of the child's death. The Committee will forward a copy of the report to the Executive Director of the Society and to the Assistant Deputy Minister of the ministry's Program Management Division. Program Management Division will forward copies of the report to the Regional Office and to the ministry's Policy Development and Program Design Division.
  11. The Society will consider the Paediatric Death Review Committee Report, will implement the recommendations as appropriate and will incorporate the recommendations addressed to the Society into its written progress reports to the Regional Office.
  12. The Regional Office will maintain copies of reports, reviews, recommendations and related statistics in accordance with the ministry's Records Management Procedures.

Effective Date: March 31, 2006

Original signed by:

Trinela Cane
Assistant Deputy Minister
Program Management Division
Ministry of Children and Youth Services
Ministry of Community and Social Services

Alexander Bezzina
Assistant Deputy Minister
Program Management Division
Ministry of Children and Youth Services
Ministry of Community and Social Services

Dr. James Cairns
Deputy Chief Coroner
Ministry of Community Safety and Correctional Services

Back to top