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.