Indigenous young people, their families and communities

The Panel found that despite complex histories and the high-risk nature of these young people’s lives, intervention was minimal and sometimes non-existent. The environments where they were living often did not foster a continued sense of purpose or belonging. Frequently, they did not appear to be encouraged to be hopeful about their futures or to have positive aspirations – a finding that was consistent with what the Panel heard from youth with lived experience.

The identities of marginalized young people were not incorporated into service delivery or care. Indigenous, Black and LGBTQI2S young people were not consistently connected to identity-based or culture-based programs, nor was their identity incorporated into their care. There were minimal efforts made toward inclusivity.

Eight Indigenous lives

Eight of the 12 young people were Indigenous. The Panel found that those young people, their families, and their communities were impacted by colonization, the legacy of residential schools, and intergenerational trauma. In spite of this, the Panel saw evidence that Indigenous communities continue to persevere, heal, and reclaim their culture and identity. The Indigenous young people with lived experience that provided input to the Panel demonstrated the value of this work; they highlighted the importance of connection to Elders, land-based teachings, traditional ceremonies, and wholistic care (see page 13 for more information on “wholistic care”).

The Panel found that the services provided to the eight Indigenous young people were largely unresponsive to these needs; there was a lack of culturally safe, trauma-informed approaches with a focus on prevention and family supports. It did not appear that they had a safe place to go on-reserve when it was needed and when they could not remain in their homes, they were often removed from their communities altogether. Following removal, there was minimal connection to Elders, land-based teachings, traditional ceremonies, and wholistic care.

The challenges faced by these young people were compounded by the systemic barriers and challenges faced by Indigenous peoples and their communities in Ontario including limited access to resources. There is evidence of inadequate shelter, water, and food in their communities and many of the young people that were the subject of review did not have equitable access to education, healthcare including, mental healthcare, social services, and recreational activities. In particular, Indigenous child wellbeing societies that serve people in remote First Nations communities have distinct constraints to delivering services that other societies do not; for example, large geographic areas.

Society involvement and placements

The Panel was struck by the lack of focus on family preservation and early intervention, and the long-term implications for the young people. All 12 of the young people reviewed by the Panel were in the care of a Children’s Aid Society or Indigenous Child Wellbeing Society (Society) at the time of their death and many of them had substantial child protection involvement throughout the course of their lives.

The young people had minimal opportunity to have a voice in their care and their attempts to communicate their needs were often overlooked, ignored and characterized as “attention-seeking.” They were not meaningfully engaged in services or programs in the community including, educational programs and mental health services, for significant periods of time.

“It’s not about how to let kids share their voice, it’s just about letting kids share their voice.”

Many of the young people were placed far away from their home communities so it was hard for them to stay connected to their families, communities, and cultures. They experienced multiple placements in short periods of time making it difficult to build relationships and form healthy attachments with their caregivers. On average, the young people had approximately 12 placements throughout their lives.footnote 1 There is currently no way to monitor and track the length of young people’s placements or the number of placement transfers they have at the systemic level. Placement selection appeared to be based on what was known to be available, rather than on goodness-of-fit or the young person’s needs.

One of the challenges with matching placements to the young person’s needs is the lack of clarity regarding the different types of placements. Despite commonly used terms for children’s residences (i.e. group home, staff-model foster home, foster care treatment, etc.), there are no clear definitions for the differences between them or the distinct services they may or may not provide. Licensing requirements and oversight are also unclear; many residences, both licensed and unlicensed, are not inspected by the Ministry of Children, Community and Social Services. This is because residences are not inspected where an operator with multiple homes is issued a license based on an inspection of 10 per cent of their homes.

While licensing may monitor compliance with operational standards in the facility, there is no process to monitor the quality of care that is being provided to young people. As there is no central database for placements, it was also clear that societies had a variable understanding of what placements were available, where they were located and the nature and quality of services they provide.

In reviewing the placement environments where the young people lived, it became clear that their basic needs were inconsistently met. Overall, the Panel determined that many received a poor quality of care which had a profound impact on them over time. They believe that the quality of care was impacted by the capacity, lack of supervision, qualifications, training, and education of staff and caregivers. While physical restraints and 1:1 supervision modelsfootnote 2 were commonly used interventions, there did not appear to be a shared understanding of when to use different intervention models or a consistent approach to them.

Mental Health Care

All 12 of the young people struggled with their mental health problems – many from an early age. The Panel found that most of them experienced fragmented, crisis-driven and reactionary services and, in some cases, no services at all. Many of the young people’s families would have benefited from additional support services, and very few of the families were able to access them, even when they were requested. The Panel observed that many of the 12 young people faced complex circumstances in their lives and in their families of origin, which may have contributed to their mental health challenges. There were concerns regarding the availability of long term and/or intensive mental health care; particularly for latency/early teenage youth. Where young people required more intensive, residential services, there was variability in access and availability of treatment beds across the province. Where young people were connected to mental health services, there was often an absence of a team approach, a lack of service coordination and accountability, and a lack of professionals equipped with the skills to adequately respond to their mental health needs.

Service systems

Roles, relationships and communication structures in the child protection system did not appear to be clearly defined. There was an apparent lack of transparency and information sharing between societies, placement providers and other child and family services. Specifically, there seemed to be confusion regarding the role and mandate of child welfare services in providing mental health care. There appeared to be an assumption on the part of other community service providers that the child welfare system has the mandate and capacity to provide mental health care and/or to promote young people’s mental health needs being met. The distinction between child protection services and mental health services are not clearly understood by families or children and youth service sectors. Challenges between service systems extended beyond role clarity; there was also a lack of service integration at the local community level in many of the young people’s communities.

System oversight

It was difficult for the Panel to determine the specific degree and nature of service providers’ involvement in many of the histories. Case files and documentation were disjointed with gaps in information, unclear service trajectories, discrepancies between agencies, and inconsistent definitions. These same challenges were felt to impact the Ministry of Children, Community and Social Services’ ability to maintain meaningful oversight. If the Panel could not determine in some cases, who was providing services and what type, it was likely that the ministry was equally unable to understand the pathways through the various systems, both at the individual level and in aggregate.

The Panel also reviewed serious occurrence reports to understand the circumstances and environments in which the young people lived. They found that the information in these reports was often not substantial and, in some cases, inaccurate. From a systemic perspective, the Panel was concerned that trends in serious occurrence reports and other documentation have not historically been monitored at the provincial level to identify opportunities for improvement.

Any analysis of service systems would be incomplete without an assessment of cost versus benefit. These young people do not appear to have received significant “benefit” from the services and supports that were in place to serve them. It was clear that it is not possible to determine the overall cost to support young people in the child protection system because it is not recorded centrally. Not understanding the costs, outcomes and experiences at an aggregate level limits the ability to provide cost-effective and high quality services that offer the potential to reduce systems costs over time.


The Panel developed five recommendations they believe would make a fundamental difference to Ontario’s young people and the overall burden on Ontario’s social service system – now and over the longer-term. The recommendations follow in abbreviated form; additional context and detail can be found in the recommendations section, which begins on page 65.

To the Government of Canada and the Government of Ontario:

  1. Immediately provide equitable, culturally and spiritually safe and relevant services to Indigenous young people, families and communities in Ontario.

To the Ministries of Children, Community and Social Services, Education, Health and Long-Term Care, and Indigenous Affairs:

  1. Identify and provide a set of core services and support an integrated system of care for young people and their families across a wholistic continuum to every child in Ontario. Services must include health, mental health and wellbeing, education, recreation, child care, children’s mental health, early intervention services, prevention services and developmental services. Service provision should be geared to the needs and intensity of needs, of each young person and family.
  2. Develop a wholistic approach to the identification of, service planning for and service provision to high-risk young people (with or without child welfare involvement) that supports continuity of care to age 21 years.
  3. Strengthen accountability and opportunities for continuous improvement of the systems of care through measurement, evaluation and public reporting.

To the Ministry of Children, Community and Social Servicesfootnote 3

  1. Immediately enhance the quality and availability of placements for young people in care.


The Panel identified 10 principles that underpin their recommendations:

  1. All young people must be involved in and at the centre of their care and be given the ability to influence their care based on their knowledge of themselves and their situations. Their voices must be heard, believed and prioritized.
  2. All young people must have the opportunity to learn about, understand and experience their history, culture and its customs and teachings.
  3. The care of and service provision to young people, families and communities must be wholistic, prevention-focused, and driven by their needs. It must ensure that the physical, mental, emotional and spiritual needs of young people are met.
  4. Indigenous communities must be enabled, supported and funded to bring forward their needs and to further develop their methods of addressing their needs.
  5. Indigenous communities must be enabled, supported and funded to self-govern in a nation-to-nation relationship with Ontario.
  6. Caring is an action. Care must be provided with a continued sense of purpose and a focus on the young person’s future.
  7. Caring is a shared responsibility that crosses organizational, sectoral, geographic and jurisdictional boundaries. Barriers between systems must be eliminated or be made unnoticeable to clients.
  8. Children must be kept at home wherever possible – and when it is not possible, they must be in stable, nurturing placements for as long as required that ensure as few moves and transitions as possible. 
  9. Services must be provided to young people and their families where they are, wherever possible. Where it is not possible, distances should be minimized. 
  10. All young people must be in school or participating in equivalent learning.​


  • footnote[1] Back to paragraph The average number of placements is approximate because in some of the young people’s case documents, there are gaps for periods of time where placement transfers cannot be confirmed.
  • footnote[2] Back to paragraph This refers to the ratio of staff working with a child.
  • footnote[3] Back to paragraph Formally the Ministry of Children and Youth Services (MCYS).