PDRC — child welfare reviews of cases with society involvement in 2018
All child deaths are tragic and typically have a number of contributing factors. Occasionally, the actions or inactions by those in a caregiving role (e.g. family members or the child welfare system) may have played a part in the circumstances of the death. The Paediatric Death Review Committee – child welfare reviews the circumstances of the death and may make recommendations to the health care sector, child welfare systems and others with a goal to reduce the number of child deaths and/or to improve the services and care provided to children, youth and families. It is anticipated that by examining these cases with a non-blaming approach, we can learn from individual deaths to improve the lives of other children.
Reports received by the PDRC – child welfare in 2018
PDRC – child welfare cases reported to the Committee are usually not reviewed within the same calendar year in which death occurs. Committee reviews in any given year will include review of deaths occurring in different years (see Chart 24). This results from a number of factors, including: complexity of the investigation, time allotment for completion of other reviews (for example, DU5C), case volume, and other parallel investigations or proceedings, including involvement of the criminal justice system.
In 2018, as required by the Joint Directive, 126 deaths of children and youth were reported by Societies to the PDRC – child welfare, which included 119 children and youth aged 0-18 and seven youth aged 19-21 who were receiving Continued Care and Support Services supports from a society at the time of their death. These cases are at various stages of the PDRC review process.
Chart 23 illustrates the status of review for the 126 cases reported to the PDRC – child welfare in 2018. 34% of cases did not require a full PDRC review and 49% of cases are pending a decision.
Chart 23: PDRC status of 2018 deaths with Society involvement
| Status | Number of cases |
|---|---|
| Closed: A PDRC Executive Review has taken place, and no full PDRC review is planned. This occurs when the circumstances surrounding the child’s death do not relate in any way to the reasons for services and/or the Society involvement. | 43 (34%) |
| Pending Decision: Cases may be pending a decision regarding PDRC review because additional information is required or because there are other pending investigations or criminal justice system involvement | 61 (48%) |
| Full PDRC Review to be Undertaken: An internal child death review has been requested from the Society, and the PDRC will undertake a full review of the case. | 14 (11%) |
| Full PDRC Review Completed: An internal child death review was requested from the Society, and the PDRC has undertaken a full review of the case. | 8 (6%) |
Reports reviewed by the PDRC – child welfare in 2018
Following the process outlined in Chart in Appendix A, the PDRC - child welfare reviewed the deaths of 17children and youth who had involvement with a Society within the 12-month period leading up to their deaths in 2018. Fewer cases were reviewed in 2018 than in previous years due, in part to the efforts dedicated to piloting the Data Integration and Local Death Review Table projects as part of the work to operationalize the Child and Youth Death Review and Analysis (CYDRA) model.
Chart 24 illustrates the year of death for those cases reviewed by the PDRC – child welfare in 2018. The majority, 12 of the 17 cases reviewed in 2018 were of deaths that occurred in 2016 and 2017. The year of death for those cases reviewed in 2018 ranged from 2012 – 2017.
Chart 24: Year of death of 2018 PDRC case reviews
| Year of death | PDRC cases reviewed in 2018 |
|---|---|
| 2012 | 2 |
| 2013 | 0 |
| 2014 | 2 |
| 2015 | 1 |
| 2016 | 7 |
| 2017 | 5 |
| 2018 | 0 |
| TOTAL | 17 |
Of the 17 cases reviewed by the PDRC in 2018, 8 were males (47%) and 9 were females (53%).
The age of the children and youth at the time of their death ranged from 35 days to 18 years.
Historically, a greater proportion of reviews completed by the PDRC – child welfare involve children under one and adolescents. Chart 25 demonstrates the age categories for the cases reviewed. This information illustrates that in 2018, 41% of the PDRC – child welfare’s reviews focused upon deaths of children under the age of five, 18% on children and youth age 1-4 and 24% on those ages 15-18 with a smaller percentage on those ages 5-9 (12%) and ages 10-14 (6%).
Chart 25 demonstrates the age categories for the cases reviewed in 2018. This information illustrates that in 2018, 59% of the cases reviewed at PDRC – child welfare focused on the deaths of children and youth under age of 5, 24% on those age 15-18 and 18% on those age 5-14.
Chart 25: PDRC – Child welfare reviews across age groups 2018 (n=17)
Chart 26 illustrates the manner of death of children and youth whose cases were reviewed by the PDRC – child welfare in 2018. In 2018 there were four homicides and four undetermined deaths, three accidents, natural and suicide deaths each.
Chart 26: PDRC – Child welfare reviews across manner of death in 2018 (n=17)
Of the 17 cases reviewed by the PDRC – child welfare in 2018, 71% (12) were open to the Society at the time of death (see Chart 27)
Of the 12 cases open to a Society in 2018, a majority of the cases (4) had open protection status at the time of death, three had ongoing protection intervention, two had open investigations, two had no status and one was living independently and receiving Continued Care and Support for Youth services. Of all the opened cases PDRC reviewed in 2018, none were in the care of a society.
Chart 27 illustrates that of the 17 cases reviewed by the PDRC – child welfare in 2018, 12 (71%) were open to a Society at the time of death, while 29% of cases (5) were closed to a Society at the time of death.
Chart 27: PDRC – Child welfare reviewed cases in 2018 open vs. closed (n=17)
