Chart 29 shows the process and timelines arising from the 2006 Joint Directive between the OCC and MCYS for Child Death Reporting and Review.

Chart 29: Joint directive flow chart – Office of the Chief Coroner and Ontario children’s aid societies 


Chart 29: full description below


Chart 29 description:

Death of a child

  • Immediately
    • Serious Occurrence Report
  • 14 days after death
    • Child Fatality Case Summary
  • 21 days after death
    • PDRC Chair advises if internal review necessary

Is an internal review necessary?

  • Yes
    • CAS has 90 days to complete internal review and provide to PDRC
    • If necessary, full CAS file to be seized - PDRC will advise
    • PDRC completes review within 1 year of child's death 
  • No
    • No further action


Society internal child death reviews

When is an internal child death review requested?

The Chair of the PDRC reviews the Society’s Child Fatality Case Summary Report and the Coroner’s Investigation Statement (CIS) and considers the following criteria when deciding if the Society will be requested to conduct and forward an Internal Review to the PDRC:

  • Meets the criteria of the 2006 Joint Directive (Society involvement within 12 months of the death)
  • When a child dies as a result of questionable circumstances; and
  • Where the circumstances surrounding the child’s death may relate in any way to the reasons for service and/or Society involvement.

Why is an internal child death review requested?

An internal child death review is requested by the Chair of the PDRC for the purposes of conducting an analysis of the context within which the death occurred.  Internal child death reviews provide an opportunity for individual Societies, and the child welfare sector as a whole, to learn from child deaths with a view to identifying areas of potential improvement to Society policies, practices and procedures. 

Who completes the Society internal child death review?

When the Chair of the PDRC requests that a Society undertake an internal child death review, the CAS is required to establish a review team which must include an independent external reviewer with appropriate clinical expertise to participate in the review.

Levels of PDRC – child welfare reviews

There are three levels of PDRC – child welfare review:

Executive Review: These cases which upon review by the Executive Committee of the PDRC, it is determined that no further review by the CAS or PDRC – child welfare is required, as the circumstances surrounding the child’s death do not relate to the reasons for services and/or Society involvement. For example, cases where the child’s family had no Society involvement until the injury leading to the death, or the child was known to CAS, but the death was natural and not unexpected, or the child died as the result of an incident unrelated to the reasons for the family’s involvement with the Society.

Pending DU5C/further investigation: On occasion, the decision to request an internal child death review from a Society is postponed pending the completion of the Coroner’s investigation and/or review by the DU5C, to await additional information and context regarding the child’s death.  

Internal and PDRC Review: If the PDRC – child welfare requests an internal child death review, Societies are requested to submit their report within 90 days, and the PDRC – child welfare has up to 12 months to review the case and issue a report that may contain further recommendations. All cases in which an internal child death review has been completed are reviewed by at least two members of the PDRC – child welfare – one police representative and one child welfare representative – review the following case material for each death with Society involvement:  the Serious Occurrence Report, Child Fatality Case Summary Report, the Internal Child Death Review, police report, Coroner’s Investigation Statement, Report of Post Mortem Examination, toxicology reports (if applicable) and any other investigative reports provided (for example, report from the Office of the Fire Marshal).  After discussion at a committee meeting, a final case report is prepared consisting of a summary of events, discussion and recommendations (if any), with a goal to inform the prevention of future deaths. The report is forwarded to the involved Society, MCYS and the referring Regional Supervising Coroner who may conduct further investigation (if indicated).

Recommendations are also distributed by the Committee Chair to agencies and organizations who may be in a position to effect implementation. Organizations are asked to respond back within one year with the status of implementation of recommendations.

Society response to PDRC – child welfare and internal review recommendations

Following receipt of PDRC – child welfare reports, individual societies consider the report and implement recommendations as appropriate. Progress reports are submitted to MCCSS Regional Offices outlining agency responses to the recommendations addressed to them. Ministry Regional Offices are responsible for follow-up with individual agencies on a quarterly basis regarding the actions taken to respond to the Internal Review and PDRC recommendations. 

Findings and recommendations from these reviews have been utilized to change practices, develop training, policy and procedures and to initiate new approaches and programs.