Print

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, and child maltreatment.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

Province/Territory 2012 status 2016 status Recommended actions Comments
British Columbia

Not assessed

Excellent

Meets all CPS recommendations.

Alberta

Not assessed

Fair

Implement a child death review committee* and a structured process to review all child and youth deaths. Process should include reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

A CDR working group in the Ministry of Health is working to establish a standardized process.

Saskatchewan

Not assessed

Fair

Implement a child death review committee* and a structured process to review all child and youth deaths. Process should include reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

The Office of the Chief Coroner is interested in establishing a formal, standardized review and reporting system on all child deaths. Work is underway. The CPS will monitor progress. 

Manitoba

Not assessed

Excellent

Meets all CPS recommendations.

Ontario

Not assessed

Excellent

Meets all CPS recommendations.

Ontario reviews deaths that fall under the Coroners Act, including all deaths of children under 5 years of age, as well as all deaths of children under 19 years of age with involvement of a Children’s Aid Society within 12 months of their death.
 

Ontario is working toward a review system that can use aggregate data from all child deaths for prevention-focused work. 

Quebec

Not assessed

Good

Implement a structured process, including reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

A formal mandate and structure are being developed.

New Brunswick

Not assessed

Good

Public reporting of investigations should be more transparent and include more details (i.e. circumstances of death) than just committee recommendations.

 

The CPS recommends that the committee review all pediatric deaths referred to the coroner, not just those selected for review by the coroner.

Province is exploring whether to review natural deaths that are not reported to Coroner Services.

Nova Scotia

Not assessed

Fair

Implement a broadly representational child death review committee* and a structured process to review all child and youth deaths, including reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

The Department of Community Services conducts internal reviews. The Office of the Ombudsman can also do reviews, with public reports.


The Office of the Ombudsman has called for the establishment of a provincial interdepartmental team to conduct child death reviews.

Prince Edward Island

Not assessed

Poor

Implement a broadly representational child death review committee* and a structured process, including reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

Newfoundland and Labrador

Not assessed

Excellent

Meets all CPS recommendations.

Yukon

Not assessed

Fair

Implement a child-specific death review committee and a linkable database for meaningful data collection, consolidation and dissemination.

Yukon reviews all child deaths but does not have a child-specific death review committee.

Northwest Territories

Not assessed

Good

Implement a structured process, including reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

Coroner’s Service wants to establish a formal, standardized review and reporting system. The CPS will monitor progress.

Nunavut

Not assessed

Fair

Implement a child death review committee* and a structured process to review all child and youth deaths – not just cases in care. Process should include reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

A death review committee is being established. The CPS will monitor progress.

Excellent

Province/territory has a broadly representational child death review committee* to review all child and youth deaths and a structured process, including reporting protocols, a linkable database for meaningful data collection, consolidation and dissemination, and an evaluative mechanism.

Good

Province/territory has a child death review committee* but no reliable data or consistent data collection mechanism and/or no system to consolidate, disseminate or evaluate recommendations.   

Fair

Province/territory only reviews cases of child or youth death while in foster care or under ministerial care, or reviews other cases but has no broadly represented child death review committee. Province/territory has no reliable data or consistent tracking mechanism and/or no system to consolidate, disseminate or evaluate committee or other recommendations.   

Poor

Province/territory does not have any form of child death review.

*Committee includes regional chief medical examiner or coroner and representatives from law enforcement, child protection services, local public health, the crown attorney, as well as a paediatrician, family physician and/or other health care provider. 

Endnotes

  1. Ornstein A, Bowes M, Shouldice M, Yanchar NL; Canadian Paediatric Society, Injury Prevention The importance of child and youth death review. Paediatr Child Health 2013;18(8):425-8.
  2. Ibid.
  3. Sidebotham P, Pearson G. Responding to and learning from childhood deaths. BMJ 2009;338:b531.