Findings from the Ontario
Paediatric Death Review
Deaths Under 5 Committee
Smart Risk Learning Series
Karen Bridgman-Acker, MSW, RSW
Motto of the Office of the Chief Coroner:
“We speak for the dead
to protect the living”
Overview of the Committees
Deaths Reviewed by PDRC in 2008
Deaths Under 5 Committee Reviews in 2008
Themes and Trends:
Accidental Fire Deaths
Key Messages for Prevention of Future Deaths
The Office of the Chief Coroner for the
Province of Ontario
Medical Coroner’s System
1 Chief, 2 Deputy Chiefs, 9 Regional Supervising
Coroners, approximately 320 Coroners
Chief Forensic Pathologist
Regional Forensic Pathology Centres
Part of the Ministry of Community Safety and
Investigates approximately 20,000 deaths per year
Investigates approximately 595 child deaths per year
Has developed a provincial Protocol for the Investigation
of Deaths of Children under age 5
Child Death Process in Ontario
Children’s Aid Society
Joint Directive: MCYS and OCC
Criteria for reporting and reviewing Child Welfare
Roles and responsibilities
Coordination of Child Welfare death reviews
Internal child death review guidelines
Analysis of Child Welfare deaths
Tracking of trends, themes, statistics and
Annual report production and dissemination
In reviewing child deaths, we all learn from:
Death Review Committees
Sharing results & recommendations
“Mistakes are a great educator when one is honest enough
to admit them and willing to learn from them”
IMPORTANCE OF INTERNAL and PDRC
Objective, “second set of eyes” (quality
Identify and track themes, trends, patterns
Contribute to collection of data, research
Learn from errors or omissions to prevent future
Disseminate 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 # 607 575 615 597 505*
TOTAL # OF 1281 1310 1335 N/A N/A
*NB: Preliminary data for 2007
Reporting and Review of
Children’s Deaths (0-19)
Manner of Deaths reviewed: Natural, Accident, Suicide,
Homicide and Undetermined
Deaths of children investigated by the Office of the Chief
Coroner of Ontario – average 598 per year (2003-2006)
Deaths of children reported by a CAS – average 93
(15.5%) per year (2006-2008)
Deaths reviewed by PDRC under the Joint Directive –
average 78 per year since 2006
PDRC and DU5C
Members with special expertise
2 of 7 multi-disciplinary expert committees at OCC
PDRC members review complex medical cases and all
child deaths where the family had an open child protection
file at time of death or within the previous 12 months
10 meetings per year; report and recommendations
disseminated to the Agency, Coroner, Ministry
Annual Report released publicly in June
DU5C reviews all deaths of children under the age of 5 and
classifies COD and MOD
Assists the Office of the Chief Coroner in the
investigation and review of deaths of children
and to make recommendations to help prevent
such death in similar circumstances
To determine the cause and manner of death
To draft appropriate recommendations for preventing
future deaths in similar circumstances
To use a “lessons learned” approach
Child Welfare experts
Paediatricians (community & hospital)
Other physicians (i.e. Sick Kids, McMaster
and London Children’s Hospitals)
What is Reviewed?
Coroner’s Investigation report
CAS Internal Review
CAS records if necessary
Medical records and post-mortem results
Annual Child Death Reviews
CAS: 60 – 70
DU5C 150 - 200
Not all deaths can be reviewed in the year of death because
Many of the 42 deaths reviewed in 2008 might have been prevented.
2008 PDRC and Internal Child Death Reviews illustrate that future
deaths can be avoided by:
Provision of safer sleep environments.
Provision of coordinated mental health resources and facilities
directed to youth identified as high risk for suicide.
More appropriate or adequate supervision of children.
Intervening before a violent act was directed at a child by a caregiver
with limited capacity to parent.
Preventable Deaths A ≠ B
PREVENTABLE ≠ RESPONSIBILITY
PREVENTABLE ≠ PREDICTABLE
PREVENTABLE means: AVOIDABLE in
2008 Reviews by Manner of Death (42)
Findings: Most High-Risk, Vulnerable Groups
Infants under 12 months
Youth between 12
and 18 years
Decrease in the # of SIDS classifications
Increase in the # of SUDI classifications
Enhanced awareness of unsafe sleeping (adult bed,
couch, crib with extra bedding, pillows, toys) and
bed-sharing as contributing factors
35% of cases reviewed at PDRC are infants < 1 year
42% of DU5C cases involve unsafe sleeping
DEATHS UNDER 5 REVIEWS in 2008
96 cases reviewed
40/96 deaths - Undetermined
33 (75%) of the Undetermined cases involved unsafe
19 (58%) of these unsafe sleeping cases involved
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)
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 2007 – U.S. National SIDS and
Infant Death Program
Product Safety Commission
2007 – Canadian Foundation for
1999 – American Medical the Study of Infant Death
Association Michigan Fetal Infant Mortality
1992/2000/2005 – American Review Network (FIMR)
Academy of Pediatrics 2008 - Health Canada Consumer
2004 - U.K. Department of Product Safety
2004 – Canadian Paediatric
2007/2008 PDRC Annual
that co-sleeping or
placing an infant in an
adult bed is a potentially
Case Example - Undetermined
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.
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 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 young
child slept in a playpen.
Cause of Death: Sudden Unexpected Death (SUDI), bed-sharing in an
unsafe sleep environment
Manner of Death: Undetermined
Note: 50% of deaths reviewed
in 2008 were Undetermined;
17/21 were found in unsafe
Possible future directions…
Training and Speciality
Example of a Public Education Initiative
Joint Protocols for investigation, reporting
and reviewing child deaths
Case conferences with all investigators
Training and Specialty
OACAS training – At Risk Infants
OCC training – Child Deaths
High Risk Infant Protocols/Policies
Adolescent 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
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%.
“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
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
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
and called 911. The parent could be rescued from the home, but
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.
The parent had fallen asleep while smoking a cigarette after having
consumed alcohol. There were no working smoke detectors in the
house. The mother had a long-standing problem with substance
Cause of Death: Smoke inhalation
Manner of Death: Accident
Note: In 2008, 10 deaths reported by a CAS and investigated by
a coroner were fire related deaths of children.
Example of a Room of Origin in a
Case Example: Homicide
H o mic id e b y
P erp etrato r
2 F ather
A 2 month old baby was brought to hospital with vital signs absent. X-rays
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
identified a skull fracture and recent subdural haematoma. The father
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 under him
and not breathing. He was later charged with Second Degree Murder and
Aggravated Assault in the death and was convicted of manslaughter.
Pikangikum First Nations
Case Example: Suicide
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
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
attempts at suicide.
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
family home. A friend (age 12) had committed suicide earlier the
same day. This youth had a history of solvent abuse as well as
previous suicide attempts.
Cause of Death: Asphyxia from hanging
Manner of Death: Suicide
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
Studies show a significant percentage of adolescents contemplate, plan or
attempt suicide without seeking or receiving help. Males are less likely
than females to seek help from any source.
(Centre for Suicide Prevention, Calgary, Alberta).
Lessons Learned - Themes
•Infants and youth comprise very vulnerable subsets of children needing
directed at reducing unsafe sleeping, suicide and fire
deaths are required more than ever.
•Issuesfacing families such as domestic violence, substance abuse and
mental health concerns are prevalent in the cases reviewed.
•The majority of cases reviewed by the PDRC showed evidence of chronic
neglect, partly related to poverty, but also to parenting capacity problems.
•The challenges faced by many of the children whose deaths were
reviewed frequently include possible fetal alcohol syndrome, physical and
emotional abuse and neglect, learning and cognitive limitations, inadequate
supervision and exposure to domestic violence.
Lessons Learned – Themes for CAS
• 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.
high risk infants, fetal alcohol syndrome, suicide risk factors)
• 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
supervision and supports provided to staff and to overall compliance with
• Finding a balance between providing support to parents who face barriers
in their role as caregivers, while also protecting the safety of, and
reducing risk to, vulnerable children is difficult.
• The PDRC noted in several reports that workers should receive additional
training, support and guidance in motivating and empowering people to
engage in services. However, CAS’s are urged to utilize legal recourses
when necessary to protect children.
• Natural causes are the most common reason that children die.
• Many child deaths are preventable; child death reviews are about understanding and
learning from the past to prevent similar events in the future.
• By identifying themes and making recommendations for best practice, it is hoped that
change, without blame, can occur.
• The safest sleeping environment for an infant is on its back in an approved crib with a firm
• 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
foreseen or prevented by a CAS.
• The most vulnerable ages for paediatric deaths are under 12 months, and between the ages
of 12 and 18 years.
• 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.
Take Home Message
The vast majority of children can
live healthy lives without incident
with the care and protection of the
adults in their lives.
Many, if not most, tragedies can
be prevented. Let’s continue to
work together to decrease the risk
of injury and death.