Coroner’s panel calls for overhaul of Ontario child protection system

A scathing report from Ontario’s coroner presses the provincial government to reform a child protection system that “repeatedly failed” 12 youths who died while in care.
“Change is necessary, and the need is urgent,” said the report, written by a panel of experts appointed by chief coroner Dirk Huyer last November to examine the spike of deaths between January 2014 and July 2017.

Chief coroner Dirk Huyer appointed a panel of experts last November to examine the spike of deaths of youth in care in Ontario between January 2014 and July 2017. Huyer said the panel’s withering report, released Tuesday, describes a system that is basically non-existent because there is “no co-ordination, (and) no integration” of services.  (Keith Beaty / Toronto Star file photo)

The 86-page report found that the 12 youths — eight of whom were Indigenous — were all in the care of Ontario’s child protection system and living in unsafe homes when they died.
The report describes a fragmented system with no means of monitoring quality of care, where ministry oversight is inadequate, caregivers lack training, and children are poorly supervised. Vulnerable children are being warehoused and forgotten.
“Despite complex histories and the high-risk nature of these young people’s lives, intervention was minimal and sometimes non-existent,” said the panel in a withering report released Tuesday.

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On average, the youths were moved to 12 different foster homes and group homes in their short lives. Lack of resources in the North resulted in most being sent to residences 1,600 kilometres from their communities, cut off from their culture. All of them suffered from mental health challenges and eight of them died by suicide.
Read more:
They loved dancing, swimming, math and science: Portraits of young people who died in care
Youth will have say in coroner’s review of group and foster home safety
Kids are going through trauma. Staff are getting assaulted. ‘We are all in the trenches together’

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In an interview, Huyer said the report describes a system that is basically non-existent because there is “no co-ordination, (and) no integration” of services.
At Queen’s Park Tuesday, Children, Community and Social Services minister Lisa MacLeod promised to move quickly.

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“From the CASs to group homes to my ministry, we all bear some responsibility,” MacLeod said, referring to Ontario’s 49 children’s aid societies. “And I want to assure the house that, as the new minister, the buck stops with me and I will take action.”
“We need to do more to make sure that children are safe and cared for. If a child dies, someone is responsible,” MacLeod added.

Children, Community and Social Services minister Lisa MacLeod promised to move quickly on the report's findings. "I want to assure the house that, as the new minister, the buck stops with me and I will take action," she said.  (Chris Young)

In an interview with the Star’s Kristin Rushowy, MacLeod said she’ll insist on more accountability from societies and group homes, more ministry inspections and more co-ordination among ministries and service providers. The government has committed more funds for mental health services, and MacLeod said she’s in talks with the health ministry to make sure the extra resources go where they’re needed.
“If we are making the decision to take a child out of their home, the supports in those group homes or other residential settings must be better than what they left and I’m setting that direction today,” MacLeod said.
Ontario’s child-protection system serves some 14,000 kids taken from abusive or neglectful parents, and helps many more in their own homes.
The panel recommended that children in struggling families should be helped at home and in their communities as much as possible. It called for a “holistic,” culturally sensitive approach to services focused on prevention and early intervention.
Nishnawbe Aski Nation (NAN) Grand Chief Alvin Fiddler spoke with MacLeod about the report Tuesday and is meeting with federal Indigenous Services Minister Jane Philpott on Oct. 2. He wants to strike a committee with Ottawa and Queen’s Park to ensure the panel’s recommendations are carried out.

“The way to honour the 12 youth who were lost, and their families, is to ensure these recommendations are fully implemented in a timely manner,” said Fiddler, adding he’ll also strike a forum to hear from the families who lost loved ones.
The health challenges faced by the Indigenous youth who died were compounded by the gross inequities their communities face, including inadequate shelter, water, food, education and health care, the panel found.
Some family members reached by the Star said they had not yet read the report. But Amy Owen’s father, Jeffrey, from Poplar Hill First Nation, north of Kenora, said he was disappointed a key point was omitted.
“Amy was supposed to have 24/7 supervision and yet why was she left alone for that long to lose her life,” he said, questioning why the report didn’t address the reason his daughter was left by herself for almost half an hour. When staff returned, Amy, one of several youth in the area who had formed a suicide pact, was found hanging. She was 13.
The coroner’s panel, which included a team of 13 youths with experience in the system, noted the young people had little say in their care. “Their attempts to communicate their needs were often overlooked, ignored and characterized as ‘attention-seeking,’ ” the panel found.
Ontario’s child advocate, Irwin Elman, was outraged by the panel’s findings: “Enough is enough. Enough loss of life. That young people should survive our province’s attempts to protect and support them is a low bar to set, but that is where we are.”

Provincial Children and Youth Advocate Irwin Elman was outraged at the findings of the report and said there had been "enough loss of life."  (Vince Talotta)

Mary Ballantyne, head of the Ontario Association of Children’s Aid Societies, said it’s clear “the system is currently failing many of these very high-needs children in particular, there’s no question about that.
“It’s not that no one has been doing anything, but clearly we’re not doing enough and we’re not doing it in the co-ordinated way that we need to do it,” she said.
The report comes on the heels of a Star investigation into a Lindsay-area group home fire, as well as Star stories about a rash of suicides and unexplained deaths of Indigenous youths in residential care.
With files from Tanya Talaga
Laurie Monsebraaten is a Toronto-based reporter covering social justice. Follow her on Twitter: @lmonseb
Sandro Contenta is a reporter and feature writer based in Toronto. Follow him on Twitter: @scontenta

By Laurie MonsebraatenSocial Justice Reporter
Sandro ContentaFeature Writer

Tues., Sept. 25, 2018