The deaths of 12 children in Ontario were the result of systems failing repeatedly to meet the fundamental needs of young people, says a report by an expert panel set up by the chief coroner and obtained by APTN News.
The 86-page report which is expected to be made public on Tuesday is a result of a year-long review led by the Ontario’s chief coroner Dirk Huyer.
Between January 2014 and July 2017 there were 12 children and youth who died while in residential care or placement of a children’s aid society or an Indigenous well-being society.
Eight of those young people were Indigenous including six from Nishnawbe Aski Nation in northwestern Ontario.
Eight of the 12 deaths were suicides, one was a homicide, two were accidental and one is listed as unknown.
“While no one individual or organization is at fault for these failures, it is important to recognize that it is people that make organizations and systems work – and people that define how they must work,” the report says.
Five of the deaths occurred within the first six months of 2017. The chief coroner came up with the seven-member panel, all of whom have expertise in areas of mental health, service systems, residential placements and government administration, not long afterwards.
Starting at the beginning of the year, the expert panel met with nine of the 12 families and visited four First Nations affected by the deaths.
The report says the panel discovered many of the young people had substantial child protection involvement for most of their lives. They all had mental health challenges and histories of self-harming behaviours and or thoughts of suicide.
Yet, they were continually silenced says the report.
“The young people had minimal opportunity to have a voice in their care and their attempts to communicate their needs were often overlooked, ignored and characterized as “attention-seeking.””
Safe spaces on-reserve for at-risk children and youth and a lack of cultural connection to elders and cultural teachings after being placed outside of their communities were among some of the challenges the panel reported.
“In particular, Indigenous child wellbeing societies that serve people in remote First Nations communities have distinct constraints to delivering services that other societies do not; for example, large geographic areas.”
Nishnawbe Aski Nation covers two-thirds of the province with 49 First Nations, many accessible by plane only.
The panel also found that the young people experienced an average of 12 different placements while in care of children’s aid and Indigenous well-being societies.
“Placement selection appeared to be based on what was known to be available, rather than on goodness-of-fit or the young person’s needs.”
The report finds that some of those placements were as far as 1,600 km away from the young people’s home communities.
“The quality of care was impacted by the capacity, lack of supervision, qualifications, training, and education of staff and caregivers,” the report says about the placements that were reviewed.
In some cases, the report said the panel couldn’t determine who was providing services and what type.
Problematic for ensuring appropriate provincial oversight of the children’s aid and Indigenous well-being societies responsible for the protection of young people, the panel says.
“It was likely that the ministry was equally unable to understand the pathways through the various systems, both at the individual level and in aggregate,” the report says.
The report has delivered a number of recommendations.
The first one calls on the Government of Ontario and Canada to “immediately provide equitable, culturally and spiritually safe and relevant services to Indigenous young people, families and communities in Ontario.”
The other recommendations are directed to the provincial ministries of children, education, health and Indigenous affairs to:
* Identify and provide a set of core services and support an integrated system of care for young people and their families across a wholistic continuum to every child in Ontario. Services must include health, mental health and well being, education, recreation, child care, children’s mental health, early intervention services, prevention services and developmental services. Service provision should be geared to the needs and intensity of needs, of each young person and family.
* Develop a wholistic approach to the identification of, service planning for and service provision to high-risk young people (with or without child welfare involvement) that supports continuity of care to age 21 years.
* Strengthen accountability and opportunities for continuous improvement of the systems of care through measurement, evaluation and public reporting.
More to come.