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No Names Allowed

January 9, 2013 permalink

Ontario's child advocate Irwin Elman is drawing attention to the failure of the province to protect children. He says most of the suggestions by coroner's juries have not been implemented. He has created a new database accessible online to show most of the suggestions. According to the Toronto Star, his hands are tied by rules preventing him from identifying children. One "fact" in the story is grotesquely wrong: 26 children have died in government custody since 1995. The best analysis is that about 60 Ontario foster children die annually. Since 1995 that makes 1080 children. Add the number dying in detention facilities to get reality.

The data can be read at the Inquest Database.



Many recommendations from child death inquests never carried out

Irwin Elman
Irwin Elman, the official advocate for children in Ontario, is launching an online database that reveals how few inquest recommendations ever get implemented in the cases of children who died in custody.

Hundreds of key recommendations to prevent the deaths of children in custody have been ignored or rejected by government agencies, the Toronto Star has learned.

Agencies responsible for protecting young wards are shielded from public scrutiny once an inquest ends through “bizarre” privacy legislation that forces the office of Ontario’s children’s advocate to keep secret any information that might identify a youth.

“It’s bizarre,” said Irwin Elman, Ontario’s Advocate for Children and Youth. “While the inquest has been public and the record is public, I cannot identify the person publicly and must even go so far as to not identify agencies.”

On Thursday, his office will launch a new online database — the only one of its kind in Canada — that tracks inquest recommendations into the deaths of children in custody. Many of these deaths have occurred in jails or within the child welfare system. In the past 18 years, there have been 26 such cases.

But the provincial act that created Elman’s position means that a great deal of relevant information will be missing from this new public record.

The act forbids him from identifying any child under provincial protection without his or her consent. And because it is impossible to obtain consent from a dead child, his office has been forced to redact from the database any information that could potentially identify anyone under the age of 18.

This includes exact dates, locations and the names of provincial ministries, associations, government-funded programs and service providers involved in a child’s death.

Elman said he has repeatedly asked the Ministry of Children and Youth Services to change the act but it has refused. “I can’t imagine (the act) was written this way on purpose,” he said.

Paradoxically, the Ashley Smith inquest will attract frenzied media coverage when it begins on Monday but he will be barred from revealing her identity.

“This person who has had their name and photo splashed across televisions and newspapers, to say we’re not going to allow him to identify her, it’s ludicrous,” he said.

Ministry spokesperson Gloria Bacci-Puhl said the confidentiality provisions of the act were crafted in consultation with the Information and Privacy Commissioner to protect the privacy and legal rights of the child.

After an inquest, any agency subject to a recommendation is given a year by the coroner to act. Of the 1,635 recommendations made since 1995, only 17 per cent had been implemented. Another 24 per cent were listed as “had or will be implemented.”

About 26 per cent of agencies did not make their response available to the coroner. Another 5 per cent had no response or a response that could not be evaluated.

Keeping tabs on recommendations through an online database will, Elman believes, force government agencies to be more accountable.

“This database is us saying that as a province we owe it to the children who have died. This is their legacy,” he said. “I hope it pushes all the sectors towards taking these recommendations seriously.”

Many of the recommendations cited in Elman’s database have been repeated over and over by inquest juries.

Recommendations are not drawn from “thin air,” says Michael Blain, counsel for Ontario’s chief coroner. Juries “must have heard some evidence to support the recommendation.”

Since 1995, at least seven different inquests have pressed for greater access to mental health assessments, treatment services and appropriate placements for youth with mental health issues.

Three-year-old Matthew Reid was in the care of a foster home affiliated with the Children’s Aid Society in St. Catharines, Ont. when a 14-year-old girl, a new ward at the home, fatally smothered him.

The inquest concluded in late 2010. So far, none of the jury’s 45 recommendations have been implemented.

A key recommendation arising from that hearing focused on improved information-sharing between government agencies.

Elman is skeptical of agencies that claim to be in the process of adopting jury recommendations.

“I would argue that if they’re still thinking about it 15 years later, that means it’s not going to be implemented,” he said.

One unnamed child welfare agency pledged to hire a quality assurance manager after the death of one of its wards. The job has yet to be filled due to “front line workload demands and budgetary restraints.” That recommendation was made more than 10 years ago.

David Meffe, 16, hanged himself while on “suicide watch” at Toronto Youth Assessment Centre in 2002. The inquest into his death revealed that jail staff had virtually no medical history for the youth; it recommended that medical records be attached to court-ordered assessments.

But this did not happen for Pickering’s Gleb Alfyorov, 17, who hanged himself with his shoelaces in an Ontario jail in 2008 while awaiting a psychiatric assessment. In fact, eight other juries had already made the same pleas for change that they made in Alfyorov’s inquest in 2011.

Michael Fraleigh, lawyer for David Meffe’s family, said privacy must be balanced against the greater good.

“While I think privacy is important, the more important work is to have inquest juries make recommendations and have them be listened to,” he said.

“If there is a name and even a face associated with the person who has passed away … it brings it home.”

With data analysis by Andrew Bailey

The Lost Children

The Toronto Star has identified seven of the 26 children who have died in government custody since 1995. Their cases appear in the provincial children and youth advocate’s new online database, which tracks inquest recommendations. While the provincial advocate is forbidden by legislation to include any information that might identify a youth in custody, the Star is not. Identities were drawn from the general timelines and the limited case details included in the database.

David Meffe, 16

In 2002, Meffe hanged himself in his cell while on “suicide watch” at a Toronto youth jail. The note he left his parents said, “Day by day it is getting worse ... This place really gets to your head.”

Many of the jury’s recommendations were implemented, including the closing of the jail and the call for strip search privacy. Some recommendations were still under consideration, among them one that there be a one-to-eight ratio of staff to youth and that security clothing be made of rip-proof material to discourage youths in custody making ligatures.

Stephanie Jobin, 13

Jobin, a severely autistic and developmentally delayed Crown ward, died after she was placed in a Brampton group home. Her heart stopped beating and she suffered irreparable brain damage after three staff members straddled her, one holding a bean bag chair over her upper body, to control her aggressive behaviour. Three days later she was declared brain dead.

The jury recommended an integrated continuum of services for children and youth with complex needs — including full-time residential care and in-home supports — be established in the nine regions of Ontario. This recommendation is listed as “under consideration.”

Matthew Reid, 3

Reid was in the care of a foster home affiliated with the Children’s Aid Society in St. Catharines, Ont., when a 14-year-old girl, a new ward at the home, smothered the young boy to death. The inquest was conducted in the winter of 2010. So far, none of the jury’s 45 recommendations have been implemented. Many of the recommendations focused on improving care for youth and information-sharing among Children’s Aid Societies,

Gleb Alfyorov, 17

In May 2008, Alfyorov hanged himself in his cell at the Syl Apps Youth Centre in Oakville while awaiting a court-ordered psychiatric assessment. A judge sent the Pickering teen to the centre for a 30-day psychiatric assessment, thinking the jail was a hospital for troubled youth. Alfyorov was strip-searched and put in a cell. No one bothered to read the court document explaining why he was there.

Before his death, eight other inquest juries had pleaded with provincial ministries and agencies to fix systemic problems like those that ultimately plagued Alfyorov. There have been repeated recommendations to curb or ban the use of solitary confinement to deal with mentally ill kids.

Juries have also asked the government to stop using privacy concerns as a reason to withhold critical information like medical records when a youth is transferred between facilities.

William Edgar, 13

A ward of the Toronto Children’s Aid Society, he fell unconscious and died on March 31, 1999 after a senior staff member restrained him at a group home near Peterborough. An inquest was called into his death because it appeared the recommendations following Stephanie Jobin’s death were being ignored. The inquest jury ruled Edgar’s death a homicide and issued 61 recommendations, most of which have been put in place, according to the database.

Katelynn Sampson, 7

Last July, Coroner David Eden called for the inquest into the Parkdale girl’s beating death. Katelynn had been found dead in her home on Aug. 3, 2008. Police later recovered a piece of paper with the same sentence scrawled 62 times: “I am A awful girl that’s why know one wants me.” Her guardians pleaded guilty to second-degree murder. An autopsy showed she had 70 wounds when she went into septic shock. The case highlighted a series of system failures that failed to stop the violence.

Jared Osidacz, 8

In 2006, the Brantford, Ont. boy was stabbed to death by his father, Andrew Osidacz, while on an unsupervised court-ordered visit. Hours later, the older Osidacz was fatally shot by police; he had also stabbed his girlfriend and her 8-year-old daughter. Three years later, an inquest jury issued 35 recommendations. Two have been implemented so far.

Source: Toronto Star

Note: There are 26 separate inquests in the index, Many have been on the internet for years, yet Mr Elman was constrained to remove parts of them. As a public service, fixcas encloses a table relating some of the Elman inquests to the unredacted versions.



 casedied name and circumstances
1590123 Nov 1997Selena Wendy Sakanee
Former CAS ward committed suicide by hanging.
20643 unknown
23425 unknown
26235 unknown
2766415 Feb 2000Joshua Douglas Durnford
CAS ward poisoned by multiple psychotropic drugs.
29513 6 Jul 2000Daniel, David, Peter and Nicole Luft
Familicide by father treated with psychotropic drugs.
3046926 Oct 1993Shanay Jami Johnson
Child returned by CAS to abusive mother.
42181 2 Apr 1996Jennifer Anne Kateryna Koval's'kyj-England
Girl killed by father on withdrawal from psychotropic drugs.
43661 3 Jul 2001Paola Rosales
CAS ward who committed suicide by hanging.
46987 unknown
5222811 Apr 1991Kasandra Hislop aka Shepherd
Girl in custody dispute and under CAS supervision killed by stepmother.
5541823 Jun 1997Jordan Desmond Heikamp
CAS ward starved to death.
6334031 Mar 1999William Edgar
CAS ward asphyxiated by restraint.
64770 unknown
6927515 Dec 2005Matthew David Reid
Foster boy smothered by foster girl.
70661 unknown
7932211 Jun 1996Angela Dombroskie, David Dombroskie, Jamie Lee Burns, Devin Burns
Four children died in a house fire.
82525 unknown
83595 unknown
8624618 Mar 2006Jared Osidacz
Foster child killed by his convicted father on an unsupervised visit.
8759413 May 2008 Gleb Alfyorov
87689 7 Sep 1996James Preston Lonnee
Young offender killed by cellmate.
8990425 May 1995Margret and Wilson Kasonde
Killed by father during custodody dispute.
91295 1 Oct 2002 David Meffe
9205812 Jan 1995Mitchell and Kenneth Free-Parkin
Unexplained deaths in family under CAS supervision.
9771320 Jun 1998Stephanie Jobin
Institutionalized crown ward died of restraint.

Monique Taylor asks Minister of Children and Youth Services Laurel Broten to implement the suggestions of the coroner's inquests. This is good politics and bad policy. Most of the suggestions from coroner's juries are for more money and power for children's aid. Ontario's families should be thankful that many have not become law.



An Open Letter to Minister Broten from NDP Children & Youth Services Critic

QUEEN’S PARK –NDP Children and Youth Services Critic Monique Taylor sent the following letter to Minister Laurel Broten, urging her to take immediate action to prevent the deaths of children and youth in the province’s care.

January 9, 2013

Dear Minister Broten,

It was with great concern that I read the Toronto Star article this morning (Inquest recommendations ignored – January 9, 2013 A1) detailingOntario’s failure to implement recommendations stemming from inquests into the deaths of children and youth living in custody.

Since 1995, there have been 26 inquests and 1,635 recommendations made. These recommendations were drafted with the sole purpose of protecting the lives of vulnerable children and preventing future deaths. Yet today, only 17% of these recommendations have been acted upon.

What this means is that 1,300 recommendations designed to prevent abuse and save the lives of vulnerable children and youth have not been put in place. This is about more than case files and bottom lines – this is about the lives and futures of some ofOntario’s most at-risk residents. These children have no one else to turn to, and it is up to us to give them the best life possible.

Why has your Ministry allowed these recommendations to sit on the shelf? I would like to be updated on your plan to ensure the full implementation of these recommendations in a timely manner.

Today, the Office of the Provincial Advocate for Children and Youth has released a partial database of these recommendations. This database will allow us to track which recommendations have and have not been acted upon. However, due to the wording of the Provincial Advocate for Children and Youth Act, 2007, the Advocate’s office must obscure details of these inquests, even when the information is already publicly available. This valuable, independent office of the legislature is hindered by faulty legislation.

New Democrats urge the government to make immediate changes to the Act—both those identified above and other longstanding issues that prevent the Advocate from doing his job—so that the needs of children and youth are better met. Will this vital task be on the legislative agenda when the House resumes?

As the Minister of Children and Youth Services, it is your job to ensure that children and youth in the care of the province are provided with the best services and protections possible. It is unacceptable that this government has willingly turned their backs on hundreds of recommendations aimed at preventing future tragedy and the obvious gaps in legislation, thereby endangering the lives of children and youth in our care.

I look forward to your timely response to these concerns.



Monique Taylor

MPP Hamilton Mountain

NDP Critic for Children & Youth Services

Source: Monique Taylor blog

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