Findings from the Ontario Paediatric Death Review
Committee & Deaths Under 5 Committee
Smart Risk Learning SeriesKaren Bridgman-Acker, MSW, RSWAugust 2009
““We speak for the dead We speak for the dead
to protect the living”to protect the living”
Motto of the Office of the Chief Coroner:
Learning Objectives
Overview of the CommitteesOverview of the Committees
Deaths Reviewed by PDRC in 2008Deaths Reviewed by PDRC in 2008
Deaths Under 5 Committee Reviews in 2008Deaths Under 5 Committee Reviews in 2008
Themes and Trends:Themes and Trends:
Unsafe SleepingUnsafe Sleeping
Accidental Fire DeathsAccidental Fire Deaths
Adolescent SuicideAdolescent Suicide
Case ExamplesCase Examples
Key Messages for Prevention of Future DeathsKey Messages for Prevention of Future Deaths
The Office of the Chief Coroner for the Province of Ontario
Medical Coroner’s SystemMedical Coroner’s System 1 Chief, 2 Deputy Chiefs, 9 Regional Supervising 1 Chief, 2 Deputy Chiefs, 9 Regional Supervising
Coroners, approximately 320 CoronersCoroners, approximately 320 Coroners Chief Forensic PathologistChief Forensic Pathologist Regional Forensic Pathology CentresRegional Forensic Pathology Centres Part of the Ministry of Community Safety and Part of the Ministry of Community Safety and
Correctional ServicesCorrectional Services Investigates approximately 20,000 deaths per yearInvestigates approximately 20,000 deaths per year Investigates approximately 595 child deaths per yearInvestigates approximately 595 child deaths per year Has developed a provincial Protocol for the Investigation Has developed a provincial Protocol for the Investigation
of Deaths of Children under age 5of Deaths of Children under age 5
Child Death Process in Ontario
Parallel Investigations:Parallel Investigations:
CoronerCoroner
PolicePolice
Children’s Aid SocietyChildren’s Aid Society
Joint Directive: MCYS and OCC(2006)
Criteria for reporting and reviewing Child Welfare Criteria for reporting and reviewing Child Welfare deathsdeaths
Roles and responsibilitiesRoles and responsibilities TimelinesTimelines Coordination of Child Welfare death reviewsCoordination of Child Welfare death reviews Internal child death review guidelinesInternal child death review guidelines Analysis of Child Welfare deaths Analysis of Child Welfare deaths Tracking of trends, themes, statistics and Tracking of trends, themes, statistics and
recommendationsrecommendations Annual report production and disseminationAnnual report production and dissemination
“Mistakes are a great educator when one is honest enough to admit them and willing to learn from them”
(anonymous)
In reviewing child deaths, we all learn from:In reviewing child deaths, we all learn from:
InvestigationsInvestigations Internal ReviewsInternal Reviews Death Review CommitteesDeath Review Committees InquestsInquests Sharing results & recommendationsSharing results & recommendations
IMPORTANCE OF INTERNAL and PDRC DEATH REVIEWS
Objective, “second set of eyes” (quality Objective, “second set of eyes” (quality assurance)assurance)
TransparencyTransparency Identify and track themes, trends, patternsIdentify and track themes, trends, patterns Contribute to collection of data, researchContribute to collection of data, research Learn from errors or omissions to prevent future Learn from errors or omissions to prevent future
deathsdeaths Disseminate results to improve outcomesDisseminate results to improve outcomes
Context of Paediatric Deaths in Ontario (0-19)
Manner 2003 2004 2005 2006 2007*
NATURAL 220 231 218 212 161
ACCIDENT 228 203 235 227 189
SUICIDE 73 61 65 47 64
HOMICIDE 36 28 26 39 42
UNDETERMINED 50 52 71 72 49
TOTAL # CORONERS CASES
607 575 615 597 505*
TOTAL # OF DEATHS in ONTARIO
1281 1310 1335 N/A N/A
*NB: Preliminary data for 2007
•45% OCC•17% CAS
Reporting and Review of Children’s Deaths (0-19)
Manner of Deaths reviewed: Natural, Accident, Suicide, Manner of Deaths reviewed: Natural, Accident, Suicide, Homicide and UndeterminedHomicide and Undetermined
Deaths of children investigated by the Office of the Chief Deaths of children investigated by the Office of the Chief Coroner of Ontario – average 598 per year (2003-2006)Coroner of Ontario – average 598 per year (2003-2006)
Deaths of children reported by a CAS – average 93 Deaths of children reported by a CAS – average 93 (15.5%) per year (2006-2008)(15.5%) per year (2006-2008)
Deaths reviewed by PDRC under the Joint Directive – Deaths reviewed by PDRC under the Joint Directive – average 78 per year since 2006average 78 per year since 2006
PDRC and DU5C
Members with special expertiseMembers with special expertise
2 of 72 of 7 multi-disciplinary expert committees multi-disciplinary expert committees at OCC at OCC
PDRC members PDRC members review complex medical casesreview complex medical cases and and all all child child deaths wheredeaths where the the family had an open family had an open child protection child protection file at time of death or within the previous 12 monthsfile at time of death or within the previous 12 months
10 meetings per year; report and recommendations 10 meetings per year; report and recommendations disseminated to the Agency, Coroner, Ministrydisseminated to the Agency, Coroner, Ministry
Annual Report released publicly in JuneAnnual Report released publicly in June
DU5C reviews all deaths of children under the age of 5 and DU5C reviews all deaths of children under the age of 5 and classifies COD and MODclassifies COD and MOD
PDRC
PurposePurposeAssists the Office of the Chief Coroner in the Assists the Office of the Chief Coroner in the investigation and review of deaths of children investigation and review of deaths of children and to make recommendations to help prevent and to make recommendations to help prevent such death in similar circumstancessuch death in similar circumstances
To determine the cause and manner of deathTo determine the cause and manner of death To draft appropriate recommendations for preventing To draft appropriate recommendations for preventing
future deaths in similar circumstancesfuture deaths in similar circumstances To use a “lessons learned” approachTo use a “lessons learned” approach
Committee Membership
CoronersCoroners Child Welfare expertsChild Welfare experts Paediatricians (community & hospital)Paediatricians (community & hospital) Other physicians (i.e. Sick Kids, McMaster Other physicians (i.e. Sick Kids, McMaster
and London Children’s Hospitals)and London Children’s Hospitals) Police detectivesPolice detectives Crown Attorney Crown Attorney
What is Reviewed?
Coroner’s Investigation reportCoroner’s Investigation report CAS Internal ReviewCAS Internal Review CAS records if necessaryCAS records if necessary Police reportPolice report Medical records and post-mortem results Medical records and post-mortem results
PDRCPDRC
Annual Child Death ReviewsAnnual Child Death Reviews
Medical: 25
CAS: 60 – 70
DU5CDU5C 150 - 200
Not all deaths can be reviewed in the year of death because of:
volume
criminal charges
incomplete investigation
Preventable Deaths Many of the 42 deaths reviewed in 2008 might have been prevented. Many of the 42 deaths reviewed in 2008 might have been prevented.
2008 PDRC and Internal Child Death Reviews illustrate that future 2008 PDRC and Internal Child Death Reviews illustrate that future deaths can be avoided by:deaths can be avoided by:
Provision of safer sleep environments.Provision of safer sleep environments.
Provision of coordinated mental health resources and facilities Provision of coordinated mental health resources and facilities
directed to youth identified as high risk for suicide.directed to youth identified as high risk for suicide.
More appropriate or adequate supervision of children. More appropriate or adequate supervision of children.
Intervening before a violent act was directed at a child by a caregiver Intervening before a violent act was directed at a child by a caregiver with limited capacity to parent. with limited capacity to parent.
Preventable Deaths A ≠ B
PREVENTABLE ≠ RESPONSIBILITYPREVENTABLE ≠ RESPONSIBILITY
PREVENTABLE ≠ PREDICTABLE PREVENTABLE ≠ PREDICTABLE
PREVENTABLE means: AVOIDABLE in PREVENTABLE means: AVOIDABLE in the futurethe future
2008 Reviews by Manner of Death (42)
Findings: Most High-Risk, Vulnerable Groups
Youth between 12 Youth between 12 and 18 yearsand 18 years
Infants under 12 months
INFANTS Emerging Trends:
Decrease in the # of SIDS classificationsDecrease in the # of SIDS classifications Increase in the # of SUDI classificationsIncrease in the # of SUDI classifications Enhanced awareness of unsafe sleeping (adult bed, Enhanced awareness of unsafe sleeping (adult bed,
couch, crib with extra bedding, pillows, toys) and couch, crib with extra bedding, pillows, toys) and bed-sharing as contributing factorsbed-sharing as contributing factors
35% of cases reviewed at PDRC are infants < 1 year35% of cases reviewed at PDRC are infants < 1 year 42% of DU5C cases involve unsafe sleeping 42% of DU5C cases involve unsafe sleeping
situationssituations
DEATHS UNDER 5 REVIEWS in 2008
96 cases reviewed 40/96 deaths - Undetermined 33 (75%) of the Undetermined cases involved unsafe
sleeping environments 19 (58%) of these unsafe sleeping cases involved
bed-sharing 11 female; 22 male 31/33 were < 7 months of age; 2 were 10 months old,
stressing the increased risk of sharing a sleep surface with very young babies.
DU5C Unsafe Sleeping Cases (33)
Bed-sharing with:
Mother – 10
Father – 3
Both parents – 2
Both + sibling – 1
Mother + sibling - 1
Babysitter - 2
Examples of unsafe sleeping scenes
Safe Sleeping Positions, Statements and Warnings
1999 – U.S. Consumer 1999 – U.S. Consumer Product Safety CommissionProduct Safety Commission
1999 – American Medical 1999 – American Medical AssociationAssociation
1992/2000/2005 – American 1992/2000/2005 – American Academy of PediatricsAcademy of Pediatrics
2004 - U.K. Department of 2004 - U.K. Department of HealthHealth
2004 – Canadian Paediatric 2004 – Canadian Paediatric SocietySociety
20072007/2008 /2008 PDRC Annual PDRC Annual ReportReportss
2007 – U.S. National SIDS and 2007 – U.S. National SIDS and Infant Death ProgramInfant Death Program
2007 – Canadian Foundation for 2007 – Canadian Foundation for the Study of Infant Deaththe Study of Infant Death
Michigan Fetal Infant Mortality Michigan Fetal Infant Mortality Review Network (FIMR)Review Network (FIMR)
2008 - Health Canada Consumer 2008 - Health Canada Consumer Product SafetyProduct Safety
“…findings support…
that co-sleeping or placing an infant in an
adult bed is a potentially dangerous practice”
Case Example - Undetermined 3 mos. old baby was found dead in the morning by the mother. The home 3 mos. old baby was found dead in the morning by the mother. The home
was described as cluttered with clothes, toys, household items and garbage. was described as cluttered with clothes, toys, household items and garbage. The kitchen had dirty dishes, baby bottles etc. littered over the counters The kitchen had dirty dishes, baby bottles etc. littered over the counters and table top. The mother was known to sleep on the couch with the baby and table top. The mother was known to sleep on the couch with the baby on a regular basis; the father and one of the other children slept on a on a regular basis; the father and one of the other children slept on a different couch or on mattresses on the floor of the living room. The other different couch or on mattresses on the floor of the living room. The other young child slept in a playpen.young child slept in a playpen.
Cause of Death: Cause of Death: Sudden Unexpected Death (SUDI), bed-sharing in an Sudden Unexpected Death (SUDI), bed-sharing in an unsafe sleep environmentunsafe sleep environment
Manner of Death: Manner of Death: UndeterminedUndetermined
Note: 50% of deaths reviewed in 2008 were Undetermined; 17/21 were found in unsafe sleeping environments.
Possible future directions…
Public EducationPublic Education
Community CollaborationCommunity Collaboration
Training and SpecialityTraining and Speciality
ResearchResearch
Example of a Public Education Initiative
Collaboration
Joint Protocols for investigation, reporting Joint Protocols for investigation, reporting and reviewing child deathsand reviewing child deaths
Information sharingInformation sharing
Case conferences with all investigatorsCase conferences with all investigators
Training and Specialty
OACAS training – At Risk InfantsOACAS training – At Risk Infants OCC training – Child Deaths OCC training – Child Deaths High Risk Infant Protocols/PoliciesHigh Risk Infant Protocols/Policies Infant SpecialistsInfant Specialists Adolescent training and programsAdolescent training and programs
Research: Paediatric Accidental Residential Fire Deaths in Ontario
Amy Chen, K. Bridgman-Acker, J. Edwards
Retrospective review of all accidental residential fire deaths of children<16
Findings 39 fire events resulting in 60 deaths
occurred between 2001 and 2006. Slightly more males than females (52 vs.
48%) and the highest incidence under age 6. Fire-playing and electrical failure were the
top two causes of fires. More fires occurred during the night (0000 to
0900) than during the day (0900-0000). Night-time fires were exclusively due to
electrical failure and unattended candles, whereas daytime fires were mostly caused by unsupervised fire-play and stove fires.
Smoke alarms were present at the scene of 32 out of 39 fire events (82%) but smoke alarm functionality was under 50%.
Findings “The high rate of CAS involvement in our study population was
expected and indicates that children from unstable families are at much higher risk of fire deaths, and thus in need of better fire protection and prevention.
Children from poor neighbourhoods and low socioeconomic families have many risk factors for fire mortality: they are more likely to live in rooms with small or no windows, and in houses with unsafe wiring and non-functional smoke alarms.
They have less supervision, and are more likely to be exposed to
smokers in the house and display fire-playing behaviour.
Interestingly, in our data set, 7 out of 12 children who died as a result of fire-play had a history of CAS involvement.
This is consistent with findings from the 2002 Portland Report, which showed 80% of the children with fire-setting behaviour lived in divided families, with 54% of the families earning less than $30,000 annually.
Furthermore, caregivers in low income families are more likely to disable working alarms due to annoyance towards false alarms activated by cooking or cigarette smoke in cramped, overcrowded living spaces”.
Recommendations 1. A working smoke alarm should be installed on every floor of the
house and in every room used for sleeping. Smoke alarms should be tested every month and cleaned every 3 months, with batteries changed once per year.
2. The importance of fire escape plans should continue to be emphasized by school fire prevention programs. Parents should practice the fire plan at least once a year with the children.
3. Level-appropriate education should be offered to all children with
history of fire-playing behaviour. Concurrent education should be available to caregivers, who should not play with fire in front of children nor leave lighters and matches in places accessible by children.
4. CAS and other agency staff who make home visits to check up on vulnerable children and their families should pay attention to the presence, location, and functionality of smoke alarms. Any non-compliance should be reported to the Fire Marshal’s Office for further investigation and subsequent resolution.
Case Example: Accident A woman awoke to find her neighbours’ home engulfed in flames A woman awoke to find her neighbours’ home engulfed in flames
and called 911. The parent could be rescued from the home, but and called 911. The parent could be rescued from the home, but firefighters were unable to enter the building again to locate the child firefighters were unable to enter the building again to locate the child who was found lying in her bed. A toddler died of smoke inhalation. who was found lying in her bed. A toddler died of smoke inhalation. The parent had fallen asleep while smoking a cigarette after having The parent had fallen asleep while smoking a cigarette after having consumed alcohol. There were no working smoke detectors in the consumed alcohol. There were no working smoke detectors in the house. The mother had a long-standing problem with substance house. The mother had a long-standing problem with substance abuse.abuse.
Cause of Death: Cause of Death: Smoke inhalationSmoke inhalation
Manner of Death: Manner of Death: AccidentAccident
Note: In 2008, 10 deaths reported by a CAS and investigated by Note: In 2008, 10 deaths reported by a CAS and investigated by a coroner were fire related deaths of children.a coroner were fire related deaths of children.
Example of a Room of Origin in a Fire Death
Case Example: Homicide
A 2 month oldA 2 month old baby was brought to hospital with vital signs absent. X-rays baby was brought to hospital with vital signs absent. X-rays revealed multiple healing fractures to his left arm and leg and fractures to revealed multiple healing fractures to his left arm and leg and fractures to the rib cage on both the right and left sides. The post mortem examination the rib cage on both the right and left sides. The post mortem examination identified a skull fracture and recent subdural haematoma. The father identified a skull fracture and recent subdural haematoma. The father indicated to the emergency personnel that he fed his son and then fell indicated to the emergency personnel that he fed his son and then fell asleep with the baby on his chest. When he awoke he found the infant asleep with the baby on his chest. When he awoke he found the infant under him and not breathing. He was later charged with Second Degree under him and not breathing. He was later charged with Second Degree Murder and Aggravated Assault in the death and was convicted of Murder and Aggravated Assault in the death and was convicted of manslaughter.manslaughter.
Pikangikum First Nations
Case Example: Suicide A female age 12 was found hanging from a tree in the community in A female age 12 was found hanging from a tree in the community in
the early morning. Her family had been looking for her the evening the early morning. Her family had been looking for her the evening before and believed that she had gone to a friend’s for the night. She before and believed that she had gone to a friend’s for the night. She was a known solvent abuser and had made at least two previous was a known solvent abuser and had made at least two previous attempts at suicide.attempts at suicide.
Three weeks after the death of his sister, a 15 yr old boy was found Three weeks after the death of his sister, a 15 yr old boy was found hanging by a shoelace from the trunk of a tree in the bush near the hanging by a shoelace from the trunk of a tree in the bush near the family home. A friend (age 12) had committed suicide earlier the family home. A friend (age 12) had committed suicide earlier the same day. This youth had a history of solvent abuse as well as same day. This youth had a history of solvent abuse as well as previous suicide attempts.previous suicide attempts.
Cause of Death: Asphyxia from hangingCause of Death: Asphyxia from hanging Manner of Death: SuicideManner of Death: Suicide
Each year, on average, 294 Canadian youth die by suicide. Suicide is the Each year, on average, 294 Canadian youth die by suicide. Suicide is the second leading cause of death for youth aged 10-24, following motor second leading cause of death for youth aged 10-24, following motor vehicle collisions. vehicle collisions.
Studies show a significant percentage of adolescents contemplate, plan or Studies show a significant percentage of adolescents contemplate, plan or attempt suicide without seeking or receiving help. Males are less likely attempt suicide without seeking or receiving help. Males are less likely than females to seek help from any source.than females to seek help from any source. (Centre for Suicide Prevention, Calgary, Alberta).(Centre for Suicide Prevention, Calgary, Alberta).
Lessons Learned - Themes•Infants and youth comprise very vulnerable subsets of children needing Infants and youth comprise very vulnerable subsets of children needing protection services.protection services.
•Prevention initiatives directed at reducing unsafe sleeping, suicide and Prevention initiatives directed at reducing unsafe sleeping, suicide and fire deaths are required more than ever.fire deaths are required more than ever.
•Issues facing families such as domestic violence, substance abuse and Issues facing families such as domestic violence, substance abuse and mental health concerns are prevalent in the cases reviewed.mental health concerns are prevalent in the cases reviewed.
•The majority of cases reviewed by the PDRC showed evidence of chronic The majority of cases reviewed by the PDRC showed evidence of chronic neglect, partly related to poverty, but also to parenting capacity problems.neglect, partly related to poverty, but also to parenting capacity problems.
•The challenges faced by many of the children whose deaths were The challenges faced by many of the children whose deaths were reviewed frequently include possible fetal alcohol syndrome, physical and reviewed frequently include possible fetal alcohol syndrome, physical and emotional abuse and neglect, learning and cognitive limitations, emotional abuse and neglect, learning and cognitive limitations, inadequate supervision and exposure to domestic violence.inadequate supervision and exposure to domestic violence.
Lessons Learned – Themes for CAS
• The PDRC often recommends that CAS staff receive specialized training The PDRC often recommends that CAS staff receive specialized training in order to help them work with the children and families they serve (i.e. in order to help them work with the children and families they serve (i.e. high risk infants, fetal alcohol syndrome, suicide risk factors)high risk infants, fetal alcohol syndrome, suicide risk factors)
• It is apparent in many of the cases reviewed that agencies continue to It is apparent in many of the cases reviewed that agencies continue to struggle with staffing and workload issues that may impact on the level of struggle with staffing and workload issues that may impact on the level of supervision and supports provided to staff and to overall compliance with supervision and supports provided to staff and to overall compliance with provincial standards. provincial standards.
• Finding a balance between providing support to parents who face barriers Finding a balance between providing support to parents who face barriers in their role as caregivers, while also protecting the safety of, and in their role as caregivers, while also protecting the safety of, and reducing risk to, vulnerable children is difficult. reducing risk to, vulnerable children is difficult.
• The PDRC noted in several reports that workers should receive additional The PDRC noted in several reports that workers should receive additional training, support and guidance in motivating and empowering people to training, support and guidance in motivating and empowering people to engage in services. However, CAS’s are urged to utilize legal recourses engage in services. However, CAS’s are urged to utilize legal recourses when necessary to protect children.when necessary to protect children.
• Natural causes are the most common reason that children die.Natural causes are the most common reason that children die.
• Many child deaths are preventable; child death reviews are about understanding and learning Many child deaths are preventable; child death reviews are about understanding and learning
from the past to prevent similar events in the future.from the past to prevent similar events in the future.
• By identifying themes and making recommendations for best practice, it is hoped that By identifying themes and making recommendations for best practice, it is hoped that change, without blame, can occur.change, without blame, can occur.
• The safest sleeping environment for an infant is on its back in an approved crib with a firm The safest sleeping environment for an infant is on its back in an approved crib with a firm
mattress.mattress.
• Involvement with a CAS is not a factor in the vast majority of child deaths in Ontario; for Involvement with a CAS is not a factor in the vast majority of child deaths in Ontario; for
those children who died while receiving CAS services, most deaths could not have been those children who died while receiving CAS services, most deaths could not have been foreseen or prevented by a CAS.foreseen or prevented by a CAS.
• The most vulnerable ages for paediatric deaths are under 12 months, and between the ages of The most vulnerable ages for paediatric deaths are under 12 months, and between the ages of
12 and 18 years.12 and 18 years.
• As the majority of children die while in the care of their families, prevention strategies and As the majority of children die while in the care of their families, prevention strategies and educational messages need to be aimed at the general public and parents, in particular.educational messages need to be aimed at the general public and parents, in particular.
Key Messages
Take Home Message The vast majority of children can The vast majority of children can
live healthy lives without incident live healthy lives without incident with the care and protection of the with the care and protection of the adults in their lives. adults in their lives.
Many, if not most, tragedies can Many, if not most, tragedies can be prevented. Let’s continue to be prevented. Let’s continue to work together to decrease the risk work together to decrease the risk of injury and death. of injury and death.