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Ontario’s system for helping children and youth at risk failed 12 young people who died in the care of the children’s aid societies or Indigenous well-being societies and an immediate overhaul is needed to prevent further loss of life, says a report by a panel struck to examine common issues in the deaths.

The Expert Panel on the Deaths of Children and Youth in Residential Placements, which was created last year by Ontario’s Chief Coroner Dirk Huyer, says in the report released on Tuesday that “change is necessary, and the need is urgent” to fix a regime that is not meeting the needs of the province’s most vulnerable, high-risk young people.

The 12 youths whose lives were examined by the panel were between 11 and 18 years old when they died. They had been placed in group homes or foster care, sometimes far away from their families. Eight were Indigenous and all struggled with developmental and/or mental-health challenges. Eight took their own lives, one was a homicide victim, two died accidental deaths and the cause of death for the final youth could not be determined.

The panel found the youths were provided with beds and supervision but were not given a sense of purpose or belonging, nor was an effort made to make them hopeful about their futures. And in the case of the Indigenous youth, the panel said there were no special supports to deal with the intergenerational trauma of colonization and residential schools.

“As a society, we owe a duty of care to these young people; a duty of care that we suggest cannot be met by the system in its current state,” the panel’s report says. “We believe that in order to meet their needs, a reorientation of the service system – including all services to young people, their families and communities – is necessary.”

The panel said it was struck by the lack of focus on family preservation and early intervention when children are determined to be at risk. The young people had only a minimal voice in their care and their attempts to communicate their needs were often overlooked. As for mental-health care, the panel said the youth experienced fragmented and crisis-driven services and, in some cases, no services at all.

Jane Philpott, the federal Minister of Indigenous Services, said in a telephone interview that the challenges faced by Indigenous children in care has been a long-time concern for her, and her department has already started addressing some of the issues highlighted in the report. Ms. Philpott said that includes providing supports that will allow children who are deemed to be at risk to stay in their homes and avoid being taken into care in the first place.

Lisa MacLeod, the Ontario Minister of Children, Community and Social Services, said in a statement that the deaths of the children were both heartbreaking and unacceptable and that her government is committed to bringing about swift changes.

One of 12 who died was Jazmine, who went to live with her grandmother in a First Nations community after her parents separated when she was 10 years old. That same year, she engaged in self-harming behavior and talked about suicide. By the time she was 12, Jazmine was diagnosed as having a mood disorder and problems related to abuse and neglect.

But over the next seven months, the report says, she received inconsistent and limited counselling, was prescribed no medication and received no further help despite a documented concern that her needs were beyond her grandmother’s ability to cope. She hanged herself after a dinner with relatives.

“This report shows the urgent need for change in the care of at-risk youth,” said Alvin Fiddler, the Grand Chief of the Nishnawbe Aski Nation, which represents First Nations communities that were home to a number of the children who were part of the investigation. “We will propose that the federal and provincial governments task a committee with the implementation of these recommendations so that these tragedies are not repeated.”

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