Do good intentions trump the lives of children suffering in Ontario's child protection system?

Do good intentions trump the lives of children suffering in Ontario's child protection system?
Posted on June 29, 2017 | Derek Flegg | Written on June 29, 2017
Letter type:
Blog Post

Author's Note:

Author's Note:

In a National Post feature article in June 2009, Kevin Libin portrayed an industry in which abuses are all too common. One source, a professor of social work, claims that a shocking 15%-20% of children under CAS oversight suffer injury or neglect. Several CAS insiders whom Libin interviewed regard the situation as systemically hopeless. A clinical psychologist with decades of experience advocating for children said, “I would love to just demolish the system and start from scratch again.”

“It is stunning to me how these children... are rendered invisible while they are alive and invisible in their death,” said Irwin Elman, Ontario’s advocate for children and youth. Between 90 and 120 children and youth connected to children’s aid die every year. (rendered invisible by the PDRC)

The PDRC isn't at all about preventing the deaths of children in care, it's about preventing real investigations into the death of each child and saving a lot of money while insiders like OACAS CEO Scary Mary Ballantyne maintain the status quo year after year. 

Ask yourself this, have the number of deaths of children in care gone down any at all since the PDRC was formed? The quick answer is no. The PDRC is nothing more than a rubber stamp absolving the children's aid society and the government of responsibility for the deaths of children in care that won't be missed. The children of the poor, the underprivileged, the mentally ill and the drug addicted.

Children aren't the only vulnerable members of society but they are the only one that's a commodity diverting tens of billions of tax dollars across Canada every year. 

William and Lila Young would have been considered pioneers of child welfare in Canada - until they couldn't hide the bodies anymore and they didn't have a PDRC to absolve them.

Don’t ‘blow up’ Ontario’s child welfare system.

Those who call for the overhaul of Ontario's children's aid societies fail to understand the many ways in which our system excels.


Let's compared the Coroner’s Death Investigations in Ontario to the children's aid society PDRC report.

But first: Is the PDRC really an independent committee when the CEO of OACAS holds a seat on it?

How did 92 children in care die between 2008/2012 according to the Ontario PDRC report? The PDRC say it's a complete mystery and no further investigation is required. Between 2008/2012 natural causes was listed as the least likely way  for a child in care to die at 7% of the total deaths reviewed while "undetermined cause" was listed as the leading cause of death of children in Ontario's child protection system at only 43% of the total deaths reviewed.

The written PDRC report.

The little PDRC pie chart that knew too much.

Ontario Coroner's Report.
47,308 Total Investigations between 2012/14

28,103 Total Cases                                                     
3,875 Total Suicide Cases                               
13,407 Total Accident Cases
518 Total Homicide Cases
197 Total Human Remains Investigations
1,208 Total Undetermined Cases

The Ontario Coroner was unable to determine the cause of death only 2% of time out of total number of deaths in Ontario. See PDF below.

Family and Children's Services of Frontenac, Lennox and Addington "Welcomes the 2016 Paediatric Death Review from the Office of the Chief Coroner? Read it:

Child and youth death review

The death of a child is a tragic event and perhaps all the more so when it could have been prevented. Major causes of death in childhood and adolescence in Canada include sudden death in infancy, congenital and medical disorders, unintentional injuries, suicide, homicide, child maltreatment and other undetermined causes. 51

There are currently no national standards in Canada for child death investigations, data collection around the circumstances of a child’s death, or death review processes. Only a few provinces have formal child death review systems. Several other jurisdictions have a child death review committee, but these groups tend only to review cases of children in foster care or whose care is overseen by an appropriate government ministry. Such committees may not have proper or consistent data collection mechanisms. The lack of standardized data makes it difficult to implement effective prevention and intervention strategies, provincially or nationwide.

To ensure evidence-informed injury prevention programs and policies, the Canadian Paediatric Society recommends that a comprehensive, structured and effective child death review program be initiated for every region in Canada. Processes should include systematic reporting and analysis of all child and youth deaths and mechanisms for evaluating the impact of case-specific recommendations.52

The importance of having a child death review process – including data collection – is well established in many countries. Research shows that standardized approaches have significant positive outcomes, such as effective injury prevention campaigns and legislative changes that truly safeguard the lives of children and youth.53

As per the Joint Directive for the reporting and reviewing of all child deaths known to a children’s aid society within 12 months of the death.


The CAS that provided service to the family submits a serious occurrence report and within 14 days of the death submits a Child Fatality Case Summary Report to the PDRC. The Executive Committee of the PDRC screens these reports and, within 7 days, a decision is made whether the CAS will be required to complete an - Internal Review - for the purposes of a future PDRC review.

Should the children's aid society be entrusted to conduct any part of a child in care death investigation/review?

By the end of the reports and the PDRC process all relevant data about the deaths of children in care has been reduced to a  pile of quantitative data and a bunch of pretty pie charts. Quantitative Data Definition: Data that can be quantified and verified, and is amenable to statistical manipulation.

The decision to request an Internal Review is based on the criteria set out in the Joint Directive.

Explanations: Executive Review Only: Are cases which, when reviewed by the Executive Committee of the PDRC (Chair and Coordinators), it is determined that no further review by the CAS or PDRC is required, as the death could not reasonably have been prevented or predicted by a CAS or medical intervention.

In cases where the cause of the death of a child in Ontario's care frequently can not be determined, should the PDRC recommend...

A - Calling in an expert on mystery deaths and re-examine the body.

Or, B - Closing the report and say nothing.

Which one do you think the PDRC chooses every time, A or B?


“It is stunning to me how these children... are rendered invisible while they are alive and invisible in their death,” said Irwin Elman, Ontario’s independent advocate for children and youth. Between 90 and 120 children and youth connected to children’s aid die every year.

Are Deaths in Custody Treated Any Differently Than Deaths In Care?

Death of an Inmate: Notifications and Funeral Arrangements - CSC-SCC
Following the death of an inmate, the Institutional  will not interfere with a crime scene or investigation.

Jump to Responsibilities and Procedures - 

The Institutional Head/District Director will ensure:
staff comply with processes identified in:

CD  568-1  ’ Recording and Reporting of Security Incidents
CD  568-4  ’ Preservation of Crime Scenes and Evidence
CD  784  ’ Information Sharing Between Victims and the Correctional Service of Canada

Read more here: 

In a ten year period from 2001-2002 to 2010-2011, 530 offenders died in federal custody from a range of known causes, including natural death, suicide, accident and homicide. During this period, suicides accounted for 17.4% (or 92 deaths) of all federal offender deaths. Another 5.5% (or 29 deaths) were homicides. The suicide rate is approximately 70 per 100,000 for federally incarcerated offenders, which is 6 times higher than Canada's 2009 rate of 11.5 suicides per 100,000 people. The homicide rate for incarcerated federal offenders was approximately 22 per 100,000, compared to the national homicide rate of 1.6 per 100,000 in 2007. (2011 Corrections and Conditional Release Statistic Overview) There were 5 inmate homicides in FY 2010-11.


No mention of any deaths by undetermined causes in custody

About The Author

Advocates for family preservation against unwarranted intervention by government funded non profit agencies.