2009 Report of the Paediatric Death Review Committee and Deaths Under Five Committee Released
Dr. Bert Lauwers, Deputy Chief Coroner for Investigations and Chair, today announced the release of the combined 2009 Report of the Paediatric Death Review Committee and the Deaths Under Five Committee.
Working under the leadership of the Office of the Chief Coroner for Ontario, the purpose of the Paediatric Death Review Committee and the Deaths Under Five Committee is to assist the Office of the Chief Coroner in the investigation and review of deaths of children and to make recommendations to help prevent deaths in similar circumstances. Committee members include coroners, medical and child welfare experts, police, Crown attorneys and pathologists.
The 2009 report contains data from deaths reviewed in 2008 when the Paediatric Death Review Committee examined the circumstances surrounding the deaths of 138 children between the ages of 0 and 19 years. The Deaths Under Five Committee reviewed 96 deaths. The purpose of the reviews is to objectively analyze the circumstances leading up to, and surrounding the deaths and to develop recommendations aimed at preventing deaths in similar circumstances. The review does not assign blame or responsibility. Most of the recommendations suggested by the committees through the reviews are focused on promoting best practices within the child welfare and medical systems, and educating the public on child safety measures.
The results noted in the 2009 report are consistent with those of previous years, which have shown that the most vulnerable ages for paediatric deaths are for infants under 12 months and children aged 12 to 18 years. The involvement of a Children's Aid Society did not appear to be a factor in the majority of child deaths. In cases where there was involvement by a Children's Aid Society, most deaths could not have been foreseen or prevented by the agency.
Upon review of the cases presented to the Paediatric Death Review Committee and Deaths Under Five Committee, common themes for the prevention of similar deaths emerged. The following themes identified in the 2009 report are consistent with the findings of previous years and should be of particular interest to parents, caregivers, child welfare agencies, health-care professionals and government ministries:
1. Unsafe sleeping environments - Infants should sleep alone, on their backs and on a surface specifically designed for infant sleep. The Paediatric Death Review Committee stresses the importance of not bed-sharing, particularly with infants under the age of 12 months. Examples of unsafe sleeping environments include: adult beds, couches, armchairs and infant swings. The sleeping environment should not contain bumper pads, toys, pillows or covers designed for adults.
2. Adolescent suicide - There is a continuing and concerning trend of adolescent suicide especially in northern aboriginal communities. A review of nine suicide deaths of children from the ages of 12 to 17 years over a 10-month period at the Pikangikum First Nations community highlights the need to examine the conditions facing this and other communities. The committee found that the consequences for these children include substance abuse, poor academic achievement, learning disabilities, problem-solving skills and poor impulse control culminating in desperation and hopelessness and ultimately, suicide.
3. 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. Issues facing families such as domestic violence, substance abuse and mental health concerns are prevalent in the cases reviewed with evidence of chronic neglect, partly related to poverty, but also to parental capacity problems.
The 2009 Report of the Paediatric Death Review Committee and the Deaths Under Five Committee is being released today at a conference hosted by the Ontario Association of Children's Aid Societies. The report is available online at: www.oacas.org or by contacting the Office of the Chief Coroner locally at 416-314-4000 or 1-877-991-9959
“All of the citizens of Ontario share a mutual responsibility to create a safe and healthy environment for our children. Opportunities for improvement will continue to be enhanced by the cooperative and appropriate sharing of information and collaboration between all parties that have a direct interest in child health, welfare and safety; all of us working together, in the interests of our children,”
Dr. Bert Lauwers