2014 Report of the Paediatric Death Review Committee and Deaths Under Five Committee

On December 1, the Office of the Chief Coroner of the Province of Ontario  released the 2014 Report of the Paediatric Death Review Committee (PDRC) and Deaths Under-Five Committee. The report includes information about all children who died in Ontario, and specific information about children who died where there was, or had been, Children’s Aid involvement.

Highlights of the report:

  • 96 deaths involving CASs were reported to the PDRC
  • 22% of the deaths were children in the North (compared with 5% of all child deaths, both CAS-involved and not, that occurred in the North)
  • 77% of the children who died were living with their family
  • 14 of the children who died were in CAS care (11 were Crown wards)
  • 30% of the cases noted multiple and high risk factors
  • 41% of cases had verified abuse and/or neglect for the child and/or a sibling
  • Disabilities were the second most common vulnerability factor: 27% had physical disabilities and 20% had emotional/mental disabilities
  • 7 children died of suicide, 5 were Indigenous children

Of the deaths reported, there are a few notable differences between CAS and non-CAS cases:

  • A higher proportion of the child deaths in the North included CAS involvement: 22% compared with 5% of all child deaths, both CAS-involved and not, that occurred in the North) (Page 22). Potential causes are noted as lack of access to health services and higher mortality rates linked to remoteness.
  • There was a higher proportion of 5 – 9 year olds and lower proportion of 15 – 18 year olds when compared to all child deaths, however the significance is not known due to a variety of factors
  • Of the children served by CASs, there are proportionately more deaths classified as “undetermined” and fewer as accident, suicide or natural causes.
  • The report recognizes the work of CASs in training and supporting families related to safe sleeping, however many variables are involved and so a direct relationship cannot be drawn.

The report lists recommendations made to the Ministry of Children, Community and Social Servicess (MCCSS) , CASs, OACAS and others and provides updates from the Ministry on eight themes, including those related to:

  • Safe sleeping
  • Risk assessment and case management
  • Discussing lessons learned with community service providers
  • Training on suicide prevention in collaboration with mental health
  • Case closure practices
  • Discharge planning with hospitals for youth at risk of suicide and medically vulnerable children and youth
  • Improve efforts to serve Indigenous children