Deaths Under Five Committee

Introduction

The Deaths Under Five Committee (DU5C) of the Office of the Chief Coroner (OCC) is a multi-disciplinary committee and members include forensic pathologists, coroners, police detectives, child maltreatment and child welfare experts, crown attorneys, a Health Canada product safety specialist and executive staff from the OCC.  Attendance for knowledge enhancement is common, including learners from different stages of medical education and detectives from police services that are not active committee members. The membership is balanced to reflect Ontario’s geography. It also includes members from several police agencies that provide diversity in terms of geographic area, size of police service and the skill set of the investigators. 

In November 2018, the DU5C was discontinued as it was determined that rigorous quality assessment of coroner’s investigations involving the deaths of children under age five years was being achieved through other mechanisms including peer reviews of post mortem examinations and the establishment of the Child Injury Interpretation Committee (CIIC). 

From November 2018 onwards, complex cases involving the deaths of children under age five, where the determination of cause and/or manner of death remain unanswered, may be referred to the Paediatric Death Review Committee – Medical (PDRC) for thorough review.

Scope and mandate

The DU5C reviewed all cases investigated by a coroner involving the deaths of children under five years of age including neonatal cases where the death was potentially linked to parental behaviour (for example, sleep circumstances/unsafe sleep environment, maternal substance use, neglect, domestic violence, etcetera) and those in which a children’s aid society or Indigenous child wellbeing society (“Society”) was involved at time of the death. The committee did not review neonatal deaths that occurred prior to discharge from hospital where no substantive issues had been identified.  

The mandate of the DU5C was to determine the cause and manner of death for all cases meeting the criteria for review. Case-specific recommendations for additional investigation, further laboratory/pathologic testing, evaluative testing of relatives or systemic improvements could arise during the review.  

Deaths Under Five review process

Cases were referred to the DU5C by the relevant Regional Supervising Coroner. Case reviews were not confined to deaths that occurred during the calendar years of this annual report. Given the complexities involved in paediatric death investigations, the investigations sometimes take a long time to complete, delaying the DU5C review. 

The DU5C review was a two-tiered “triaging” process involving an Executive Team Review and/or Full Committee Review. 

Executive team

The Executive Team reviewed cases of deaths under five that were:

• Natural deaths with defined illnesses and no issues (i.e. the deaths are “all natural” and there are no police or child welfare concerns)
• Accidental deaths that were well documented where no issues were identified (for example, motor vehicle collision, drowning)
• Homicides or criminally suspicious deaths where the case was still under active police investigation or before the courts.

The cases were received, tracked and triaged by the Executive Team, whose membership included the DU5C Chair, Executive Lead and other individuals as necessary.

Full committee

The full committee reviewed cases of deaths under five including:

• All cases where the cause of death remained undetermined after a complete investigation
• Deaths where the sleep circumstances/unsafe sleep environment may have been a potential contributor
• Potential cases of Sudden Infant Death Syndrome (SIDS)
• Natural deaths with complex medical presentations where potential investigative or pathologic issues that may affect the cause and/or manner of death had been identified
• Accidental deaths involving unusual circumstances
• Deaths resulting from head injuries that were not well documented accidental deaths (i.e. motor vehicle collision)
• Homicides (when the investigation and court process had been completed)

(Most homicides were reviewed by the Executive Team and presented to the committee prior to completion of the court process given the time period until resolution in the criminal justice system)

Cases referred to the DU5C underwent a comprehensive and detailed review of investigative materials including (but not limited to):

• Post mortem examination, toxicology results and other investigative findings
• Photographs (of the scene and post mortem examination)

• Coroner’s Investigation Statement
• Investigation Questionnaire for Sudden and Unexpected Deaths in Infants
• Police and other investigative reports (i.e. Fire Marshal and children’s aid society/Indigenous child wellbeing society reports, for example)

Chart 6 Illustrates that over the past nine years, the full DU5C reviewed between 55 and 108 cases. The manner of death for the majority of cases were “undetermined.”

Chart 6: DU5C - Full committee reviews based on manner of death 2010-2018