Message from the Chair

There have been a number of achievements made over the past two years in advancing child death investigation and review. As the new Chair of the Paediatric Death Review and Deaths Under Five Committees, it is a privilege and honour to continue the work of Dr. Dirk Huyer, Chief Coroner for Ontario and the former Chair of the Paediatric Death Review and Death Under Five Committees. The investigation and review of child deaths is an area that continues to be one of the most important and challenging parts of our mandate.  Both the Paediatric Death Review Committee (PDRC) and Deaths Under Five Committee (DU5C) exist to help us learn from child deaths in order to help prevent further deaths.  Each opportunity to learn offers an important opportunity to reduce child mortality - potentially sparing the profound grief families suffer when a young life full of promise is lost prematurely.

Enhancing these opportunities to learn is a priority for the Office of the Chief Coroner (OCC) and for others. Since 2014, we have been working with the Ministry of Children, Community and Social Services (MCCSS), formerly known as the Ministry of Children and Youth Services (MCYS) and the former Office of the Ontario Child Advocate (OCA) to develop a “best-in-class” model of review that will be data-driven, evidence informed and grounded in collaborative partnerships in an effort to maximize the potential for affecting public health analysis, policy development, research and prevention strategies in the province of Ontario.

The Child and Youth Death Review and Analysis Team (CYDRA) has been operational since December 2017 and has been granted pilot funding through by a tripartite agreement between the Office of the Chief Coroner, the former Ontario Child Advocate and MCCSS.

Recognizing that death prevention is a shared responsibility and that children, youth and families are impacted by multiple systems, the new model will aim to understand how these systems impacted their lives prior to their deaths and incorporate multiple organizations at various levels to thoroughly inform the death investigation and review process at each stage. With broader input and participation, there will be increased opportunity for timely, relevant learning, and more comprehensive data will be available to inform surveillance and help to identify trends and themes that can point to systemic issues. This is key to determining the right areas for targeting further analysis, prevention strategies and areas where research could be of benefit. 

We have developed and are in the process of piloting this new model and expect to complete the proof of concept by early 2021.

While the new model is piloted, the PDRC and DU5C have continued their valuable work.  Their thoughtful analysis continues to identify important recommendations that can make a significant contribution to community safety and are instrumental in bringing preventative strategies to the attention of organizations.  I am grateful for the hard work of the committee members and their ongoing commitment to child death review.  Their work is well documented in this annual report.

I look forward to continued work with others toward the shared goal of improving the health, safety and well-being of Ontario’s children and youth.

Dr. Joel Kirsh, MD, MHCM, FRCP(C)
Regional Supervising Coroner – Central East Region
Chair, Paediatric Death Review Committee and Deaths Under Five Committee