By policy, coroners in Ontario investigate all paediatric deaths of children and youth between the ages of 0 to 18 that occur where a Society has been involved with the child, youth or family within 12 months of the death. Consequently, some paediatric deaths that would not ordinarily meet the criteria for a coroner’s investigation are investigated solely because of the involvement of a Society.  These deaths include natural deaths that occurred in a hospital/hospice or that were expected to occur, which under normal circumstances would not likely be investigated by a coroner. In 2018, 22 paediatric deaths fell into this category. These 22 deaths have been excluded from some of the analyses undertaken in this report to allow for the comparison of deaths with Society involvement against the cohort of paediatric coroners’ investigations (which does not include natural deaths free of care related concerns). It should also be noted that a Society was involved within 12 months prior to the deaths in all the paediatric deaths that have been excluded from the analyses.

Therefore, 433 (455 deaths minus 22 natural deaths = 433 deaths) is the number used in analyses of total paediatric deaths investigated by a coroner and 97 is the number used in analyses of paediatric deaths with Society involvement (119 deaths minus 22 natural deaths = 97 deaths) for the year 2018. This is consistent with the approach taken in previous years. Figure 1 represents the deaths of children and youth in Ontario in 2018 that were subject to a coroner’s investigation.

Figure 1: This figure shows all deaths of children and adolescents in Ontario in 2018, for a total of 1,092 deaths of people aged 0 to 18. Out of these, 455 were investigated by a coroner. 119 of these cases were in the care of a Society in the 12 months preceding the death, compared to 336 cases in which a Society had not been involved. Out of the 119 cases in which a Society was involved, 22 were “natural hospital deaths” and did not require an investigation if a Society was not involved. Out of the other 97 cases in this group, 3 received traditional customary care, 12 were in placements and 82 were not. One of the people who were not in placements received Continued Care and Support for Youth. Other than these 455 young people, 7 aged 19 to 21 were supported by this program.


Figure 1: 2018 Paediatric Deaths and Coroner’s Investigations in Ontario


Diagram illustrating the process described above