Elman Reports on CAS Deaths

February 23, 2009 permalink

Today Ontario's child advocate Irwin Elman released his annual report (2 megabytes pdf local copy). While he dealt with several problems including difficulty in getting information required for his job, most of the reaction was to his report that 90 children in the care of children's aid societies died in a single year.

When the Pediatric Death Review Committee released its report, we commented that the four deaths in foster care, out of 90 child deaths, seemed miraculously low. It now appears that the 90 child deaths were all in foster care. Spread over 19,000 foster children that is 474 deaths per hundred thousand, making Ontario the deadliest jurisdiction for which there is credible foster mortality data, seventeen times more hazardous than care by mom and dad.

Today all news media in Ontario carried this story, and we can expect more to come.

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Why did 90 children die?

Ontario's child advocate was appalled to learn how many in the province's welfare system die each year and is equally shocked at how difficult it is to get answers

Laurie Monsebraaten, Toronto Star

Ninety children known to Ontario's child welfare system died in 2007, according to the latest report from the chief coroner's office – a number the province's new child advocate says is shocking and should trouble us all.

Equally disturbing, says Irwin Elman in his first annual report to the Legislature today, is the government's refusal to share detailed information on these deaths with his office.

"These are obviously very critical documents for the understanding of the events leading to the death of the child or youth, and entirely necessary for the work of the Advocacy Office," Elman writes in the report entitled 90 Deaths: Ninety Voices Silenced. "The matter of access to information is one that we will pursue vigorously."

In an interview, Elman, who has worked with youth in the care of children's aid societies in Toronto for more than 20 years, said he had "no idea" so many of these vulnerable children, who were either open cases of the CAS or had died within a year of their files being closed, could perish in a single year in Ontario. Nor did he know that the number of children who have died has been constant since the late 1990s when the Coroner's office began tracking their deaths.

When he asked medical officers of health and colleagues in child welfare, they, too, were surprised by the number and urged him to speak out, Elman said.

It is why the deaths are highlighted on the cover of his 25-page report, he said, with the face of a child whose mouth is covered by a red banner reading "90 deaths, ninety voices silenced."

Elman notes the deaths represent less than a quarter of all children who died in the province in 2007 and are a fraction of the 26,260 open cases of children's aid societies. But the number of deaths is "too high by any standard."

"These are children that we, as a province, have determined are in some peril and should be receiving the best of what we, as their parents, have to offer," he said. "So how could 90 of them die? I want all of us to be thinking about that."

Gaining more access to information about children and youth involved in the child welfare and youth criminal justice systems, and broadening his office's legal right to the coroner's files on deaths are key goals this year, he said.

"We need (this information) to help resolve issues that youth have contacted us about, to know how to respond to incidents involving children and youth in care and to investigate any deaths among our charges," his report says.

The 90 deaths in 2007 are recorded as part of the chief coroner's annual Pediatric Death Review Committee report released last June. They include children and youths in foster care, whose families had open files with a children's aid society or had died within a year of their files being closed.

Most of the deaths were preventable, the committee concluded.

Sixteen were accidental; nine were listed as suicides; four were homicides; eight died from natural causes and could probably not have been prevented; 22 were considered undetermined, which means there was no evidence for any specific classification or they fit within more than one classification; 17 are yet to be assigned a classification; and 14 were not considered appropriate by the Coroner for investigation because their deaths were expected due to fragile health.

Of the 76 classified deaths, 34 were babies younger than one year old and 24 were youths between the ages of 12 and 18.

The report provides broad geographical information about where in the province the children died, but there is no information about ethnicity, family income and community resources, or if the child was in foster care or living with parents. (In an interview, a spokesperson for the coroner's office said 14 of the classified deaths in 2007 were children in foster care.)

Prevention strategies suggested in the coroner's report include safer sleeping arrangements for babies; co-ordinated mental health services for youth; better supervision; educating caregivers early in a baby's life to be more mindful; and paying more attention to children's medical needs.

Elman says his office must focus on the deaths and strive to understand the circumstances – broad and specific – to ensure the children are safe and thriving.

"I would like to honour the kids who died by looking at their journeys and using them to help the living in as broad a sense as we can," he said. In his report, Elman says his office will request legal standing at all inquests into deaths of children in the system and will conduct an independent review of jury recommendations dating back 10 years to determine trends and gaps.

The office receives about 3,000 phone calls for help each year from among more than 20,000 children and youth in contact with Children's Aid. Those in foster care are there because of parental neglect or abuse and many feel their lives are spinning out of control, the report says. Worse, many say the stigma of being connected to the system is overwhelming.

Elman wants his office to do more to reach out and give these children a voice and a role in improving their lives. And he hopes to form regional youth reference groups so their concerns can be heard.

The report includes a section and letter addressed directly to children and youth in care, advising them of their rights and urging them to phone the office – collect if they can't access the 1-800-263-2841 number – if they need help.

"Children and youth like you have overcome tremendous barriers in the past to become loving parents, lawyers, professors, plumbers, artists, activists – you name it," Elman writes. "We are here to help you with the hard work and courage needed for you to take the risks to overcome barriers you face," he adds. "I intend to lead an office ... that demonstrates each day our belief in you."

The office will work to implement Jordan's Principle – named for a First Nations child in Manitoba – which aims to ensure conflicts over which level of government has financial responsibility to help a status Indian or Inuit child are settled after the service is provided.

For Northern Ontario, where only one advocate fields calls from 15 child welfare agencies, the report said the office will appoint a special director or deputy provincial advocate to consult with the community on how best to proceed. New measures, which likely won't take effect until later in the year, would need additional funding, the report says.

The child advocate's annual budget when the office existed as part of the provincial ministry of children and youth services was $1.8 million. But it will top $3.9 million in this, its first year as an independent office.

Still, the report notes that with a staff of just 21, including 13 advocates, Ontario has the smallest per capita staff and budget of any provincial children and youth advocate's office and may need more resources in the future to fulfill its mandate.

Source: Hamilton Spectator

Addendum: In the reader comments of the Toronto Star we found:

Only half the numbers

before anyone can make comments on these numbers, we should be provided with the amount of child deaths for the same time span of families that were investigated but the child/children NOT removed. Only then can a proper analysis be made!!!!!

Submitted by Meisje at 8:25 AM Tuesday, February 24 2009

Meisje (Dutch girl) must be a CAS worker. Well, we have found the other half of the numbers girl, and foster care is seventeen times as deadly.

In some incredible comments reported in the Toronto Sun below, Deb Matthews gets herself into deeper trouble. She says the deaths in one year of 90 children who had been through Ontario's child protection services is not an indictment of child welfare in this province. If serial killing is not an indictment, what is? She went on to say that the number of deaths of children known to provincial child welfare services has been constant since 1991. So this problem is not new, but Deb Matthews, and her predecessors, have been ignoring the slaughter for eighteen years. Good work, Deb.

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Toronto Sun

Minister stands by child-welfare system despite 90 deaths

By BRETT CLARKSON, SUN MEDIA, Last Updated: 24th February 2009, 1:38am

The deaths in one year of 90 children who had been through Ontario's child protection services is not an indictment of child welfare in this province, the McGuinty government's children's minister said.

"I think that is a conclusion that some could jump to," said Deb Matthews, the minister of child and youth services. "I don't think it's the right conclusion."

Matthews was responding to the annual report released yesterday by provincial children's advocate Irwin Elman.

Citing numbers released by the Office of the Chief Coroner's pediatric death review committee in June, 2008, Elman's report said the 90 children and youth who were known to Children's Aid Societies and who died in 2007 "is too high by any standards."

According to the report, 16 of the deaths were considered accidental, nine were suicides, four were homicides, eight were from natural causes, 22 were considered to be from an undetermined cause by the coroner, 17 are still to be classified, and 14 were not considered appropriate for investigation because the death had been expected due to illness.

In the legislature yesterday Matthews, responding to questions from NDP Leader Howard Hampton, said the number of deaths of children known to provincial child welfare services has been constant since 1991.

Elman, who said he had been told by the ministry that the number has stayed in the area of between 80 and 90 deaths a year since 1991, said that figure "shocked" him.

Source: Toronto Sun

Addendum: Two more articles from the Hamilton Spectator. In the first the reporter mentions four deaths in Hamilton, all outside the foster care system. The second reports the opinion of Hamilton CAS executive director Dominic Verticchio, who diverts our attention to three children dying in a tragic non-foster care house fire. This is right out of our script for dealing with foster deaths — blame the specific cause of death: swimming pools, guns, dogs or in the current case fires. Sorry Mr Verticchio, we now have the numbers. The biggest danger to children is not fires, pools, guns or dogs. It is foster care. Seventeen times as deadly as care by mom and dad.

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Child advocate 'stonewalled' on deaths

Seeking info on 90 kids who died in welfare system

February 24, 2009, Laurie Monsebraaten and Tanya Talaga, Toronto Star, (Feb 24, 2009)

Queen's Park is "stonewalling" the provincial child advocate in his bid to get more information about 90 children in Ontario's child welfare system who died in 2007, says New Democratic Party Leader Howard Hampton.

"We are talking about children under the control of children's aid societies. These are troubled children, vulnerable children who are dying," Hampton said in the wake of the Irwin Elman's annual report to the legislature yesterday, which highlighted the deaths.

"As he says in his report, the government is stonewalling him, making it difficult for him to do his job."

Elman, who became the province's first independent child advocate last summer, said the government's refusal to share detailed information about the deaths with his office limits his ability to act.

"I'm not talking about doing investigations," he said yesterday. "I'm talking about having the information about my children and youth so I know what's going on with them."

He said he will "vigorously pursue" the issue by proposing an amendment to the provincial Coroner's Act to give him full access to all reports concerning the death of children and youth involved in the child welfare system.

A shaken Premier Dalton McGuinty said the deaths are "troubling."

"If we lose just one child in care that's an issue. That's a cause for concern for all of us," the premier told reporters. "We need to better understand their particular challenges and to make sure that they are not just surviving but are in fact thriving."

Four of the 90 deaths occurred in Hamilton. One -- a child under two -- had been involved with the Hamilton CAS. That child died sleeping with its caregiver. The CAS has a caseload of about 14,000.

Three more of the deaths involved children who had been receiving services from the Hamilton Catholic Children's Aid Society. Agency executive director Ersilia DiNardo said all three deaths involved young or infant children living with their birth parents. Her agency provides services to 560 families each month.

In the legislature, opposition members hammered Children's Minister Deb Matthews for blocking Elman's access to detailed reports from children's aid societies, police and others in contact with a child before a death that are routinely submitted to the chief coroner's Pediatric Death Review Committee for review and analysis.

Matthews said the coroner has a detailed process of reviewing all child deaths. "When the coroner recommends that changes be made, we make those changes."

In an interview, Matthews said her ministry "fully supports the child advocate" and has drafted a protocol to ensure Elman's office gets information he requests about children currently in the system within 10 days. But she refused to comment on possible changes to the Coroner's Act because it's not within her mandate.

A spokesperson for Community Safety Minister Rich Bartolucci, whose ministry oversees the act, said the chief coroner's office has met several times with Elman to discuss the matter and is trying to work out privacy concerns.

However, Bartolucci "isn't considering changes to the Coroner's Act" at this time, said Laura Blondeau in an e-mail.

Children's aid societies say they are leery of the child advocate gaining access to detailed information about deaths of children in the system.

"The issue of children who have died I think is clearly and extensively covered by the role of the coroner's office," said Virginia Rowden, director of social policy for the Ontario Association of Children's Aid Societies which represents 51 of the province's 53 CASs. "We feel the coroner has an appropriate process in place for reviewing child deaths. It's very in-depth. It's multi-disciplinary," she said.

Source: Hamilton Spectator

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Children's aid groups focus on fire safety

February 24, 2009, The Hamilton Spectator, (Feb 24, 2009)

Fire safety is one of the biggest issues for the Hamilton child welfare system.

Dominic Verticchio, executive director of the Children's Aid Society of Hamilton, made the comment in connection with the release of a provincial report revealing 90 children known to Ontario's child welfare system died in 2007.

Verticchio's comment was related to the tragic west Hamilton fire in March 2008 that saw three children perish in a blaze that also claimed two adults.

Those children had been the subject of CAS involvement, Verticchio said.

Fire officials found no evidence of working smoke detectors in the home where the three children -- aged 4, 2 and 1 -- and two adults died.

That fatal fire was devastating for the Hamilton CAS and served as the impetus for the agency to get involved with the Ontario Fire Marshal's office to raise awareness of the need for working fire detectors.

The CAS has been involved with producing large refrigerator magnets to highlight fire hazards.

"We don't take fire safety as liberally as we have in the past," Verticchio said yesterday.

Many of the agency's clients are renters who aren't aware of the importance of having working smoke detectors, he added.

Ersilia DiNardo, executive director of the Hamilton Catholic Children's Aid Society, said fire safety is a concern for her agency, as well.

"We do have a number of families who live in rental situations and they are occupied with more pressing needs and may not pay as much attention that the fire alarms are working properly," she said, adding her agency hasn't had families involved with fatal fires.

DiNardo said while the number of child deaths is a concern, "I don't believe the system is failing."

She noted that the system has a number of checks and balances and a high level of accountability and scrutiny.

Source: Hamilton Spectator

Addendum: Now we have the official word from Jeanette Lewis: "the child welfare system was not a factor in the vast majority of deaths and most deaths could not have been foreseen or prevented by a CAS." The first step in fixing a problem is recognizing that there is a problem. Will children's aid ever take that first step?

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Feb 26, 2009 04:30 AM [ letter to the editor, Toronto Star ]

Re: Ninety dead children, Editorial Feb. 24

The death of a child is devastating and we need strong voices to advocate for their well-being. However, the Child Advocate's recent report brings more confusion than clarity due to misrepresentation of numbers and facts.

Last year, the Chief Coroner's Office found that the child welfare system was not a factor in the vast majority of deaths and most deaths could not have been foreseen or prevented by a CAS. It recommended that we work together to prevent deaths from unsafe sleeping conditions for infants, drowning, accidents and teen suicides.

We all want the best outcome for children. Let's find ways to collaborate and help each other by using the right information for the right purposes.

Jeanette Lewis, Ontario Association of Children's Aid Societies

Source: Toronto Star

Addendum: A report on the number of deaths in Waterloo

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Seven of 90 deaths in child advocate's report in the region

Local official singles out suffocation while sharing parents' bed as a major culprit

February 24, 2009, Frances Barrick, RECORD STAFF, WATERLOO REGION

Seven of the 90 children known to Ontario's child welfare system who died in 2007, were from Waterloo Region.

Peter Ringrose of Family and Children's Services of Waterloo Region called the seven deaths "extremely high."

The 90 deaths from 2007 represent the most recent statistics from Ontario's chief coroner, they were contained in a report to the legislature by the province's child and youth advocate yesterday.

Ringrose is concerned that unsafe sleeping arrangements have caused too many baby deaths.

"It is clearly an issue," said.

Of the seven deaths, four of the babies died of suffocation after sharing a bed with a parent, who either rolled ton top of the infant ended, or the baby rolled over and ended up sleeping on its stomach.

Sleeping on their backs is a safest position for babies, he said.

The infants ranged in age from one month to 15 months.

None of the babies were in foster care or were Crown wards.

All four died at home and the agency had contact with their parents because of issues with the families, Ringrose said.

Of the three remaining babies who died, one was medically fragile and died in a local institution, another died from a sudden illness and the death of a three-month-old girl involved a police investigation. The infant's mother, Paula Lee, is charged with first-degree murder.

In his report, Irwin Elman, who became the province's first independent child advocate last summer, said the government's refusal to share detailed information about the deaths with his office limits his ability to act.

He said he will "vigorously pursue" the issue by proposing an amendment to the provincial Coroner's Act to give him full access to all reports concerning the death of children and youth involved in the child welfare system.

In an interview, Children's Minister Deb Matthews said her ministry "fully supports the child advocate" and has drafted a protocol to ensure Elman's office gets information he requests about children currently in the system within 10 days.

A spokesperson for Community Safety Minister Rich Bartolucci, said the chief coroner's office "isn't considering changes to the Coroner's Act" at this time.

Children's aid societies say they are leery of the child advocate gaining access to detailed information about deaths of children in the system.

"The issue of children who have died I think is clearly and extensively covered by the role of the coroner's office," said Virginia Rowden, director of social policy for the Ontario Association of Children's Aid Societies which represents 51 of the province's 53 CASs.

In 2006 and 2007, 41 baby deaths in Ontario were attributed to bed sharing.

This led the Ontario coroner's office to call bed sharing "a genuine public safety issue."

Last year, the regional health unit conducted a public awareness campaign urging caregivers to ensure infants under one sleep on their backs.

Ringrose said the safest place for babies to sleep on their backs is in their own crib and adults should not share the same sleeping surface.

He said the agency is working with other social agencies to help financially-strapped parents get a safe crib.

While seven deaths is higher than normal, Ringrose said in other years there have been no deaths or just a few.

He said the agency works with "a very vulnerable population" who are exposed to higher risks than other infants.

fbarrick@therecord.com, with files from Record news services

Source: Kitchener-Waterloo Record

Addendum: Here is the OACAS press release of February 26, 2009 (pdf) which was the source for press criticism.