Failing to protect children

Report slams Ontario’s child welfare system for failing to prevent 12 deaths, eight of them Indigenous.
September 25, 2018, 7:04pm

A new report by an expert panel has slammed Ontario and Canada’s child welfare system for failing to protect 12 children who died while in care between January 2014 and July 2017, and calls for “urgent” change to the system.

The report looks at one death that gained national media attention, the case of 14-year-old Azraya Kokopenace, who ran away from hospital and committed suicide in April 2016. Kokopenace, from Grassy Narrows First Nation, had a history of suicide attempts. Her parents are still seeking answers about how she died.


In one surprising new detail, the report says there was “no rationale” provided for why the girl’s group home stopped supervising her in the days leading up to her death. It also says a care worker went to the hospital the evening of her death, but it does not lay blame or say who was responsible for her supervision that evening.

Of the cases the panel examined, eight of the children were Indigenous and one was black. Many identified as LGBTQI2S. They ranged in age from 18 to just 11 years old.

Eight died by suicide, and another by homicide. Two deaths were deemed accidental and the cause of one death was marked undetermined.

The long-awaited report from the Office of the Chief Coroner did not single out any one person or service as responsible for their deaths. A disclaimer at the top of the report says it is not intended to be used for litigation or other court proceedings.

Instead the report looks at system failure. It says the province’s child welfare system is “largely reactive,” “operates in silos” and uses a safety assessment tool that frequently found children to be “safe with intervention” when, in fact, they were not safe at all.

The safety assessment tool has three options: “safe,” “unsafe,” and “safe with intervention.” Often, the 12 young people were marked “safe with intervention” following self-harm, suicide attempts and suicidal ideation. In practice, “safe” equalled “a bed to sleep in” and “intervention” simply meant supervision — “actions that are merely a postponement until the next crisis rather than providing meaningful supports to parents and young people,” the report says.


The panel reviewed 4,000 pages of summaries of the services the children received, and 100,000 pages of records. Nine of the 12 families along with leaders from four First Nations gave the panel additional information. The panel also met with young people who had been through the foster care system.

“Change is necessary, and the need is urgent,” the report urges. “We ask those in positions of power and influence who are responsible for the functioning of the systems, be accountable for fixing them.”

In response to the report, Lisa MacLeod, minister of Children, Community and Social Services, issued a press release saying "we are taking action," however the minister did not commit to implementing all the expert panel recommendations.

Preventable deaths

Some names were changed in the report for privacy reasons. The stories in the report are extremely disturbing.

The 12 young people struggled with mental health issues, substance use, and developmental issues from fetal alcohol disorder. All of them had histories of self-harm, suicidal ideation and suicide attempts. “Collectively, they represented a cross-section of the most vulnerable, high risk young people in Ontario,” the report states.

They were placed in the care of Children’s Aid Societies or Indigenous Wellbeing Societies.

In Ontario, child welfare services are provided by 38 independent Children’s Aid Societies and 11 Indigenous Child Wellbeing Societies. Overall, the panel found they received “a poor quality of care” that had “a profound impact on them over time.”


The report provides summaries of each case. In Kokopenace’s case, her family has been asking for answers about who was supposed to be supervising her when she ran away from hospital and hung herself in a tree across the street.

The report provides new information about the care she received throughout her life, but does not find any individual or service responsible for her death.

Following her brother’s death from mercury poisoning, the report states that Azraya experienced suicidal ideation and multiple suicide attempts, and was hospitalized several times. She was allowed to live at home, where the report says the environment was unstable and she didn’t receive mental health support. In the year leading up to her death, she bounced between hospitals, foster care, group homes and her parents’ house. Two weeks before she died, she asked an Indigenous child welfare society if she could go back into its care because of “escalating challenges” at home. The report does not name the society, but her family has said it was Abinoojii Family Services. She was placed in a group home supported by casual relief staff. She was known to be at high risk of self-harm and was under constant one-to-one supervision of a worker.

In one surprising new detail, the panel found that supervision stopped in the days leading up to her death. The panel looked through her documentation but found “no rationale” for discontinuing the supervision.

The report states that the night of her death, she was attending a house party and missed her curfew. Police were called to the party and brought her to the local hospital’s ER. Group home staff came to the hospital, and police left. A short time later, Azraya left the hospital. After a search, she was found two days later hanging from a tree across from the hospital. She had committed suicide.

Darryl Contois is the Bear Clan Patrol member who found her in the tree, where a memorial, pictured above, later sprang up. He read the report Tuesday.


“If she had a worker, why was she able to leave the hospital?” he asked as he read the report. “Where was the worker? They knew she was suicidal. That worker failed to do her job to protect her.”

In another case detailed in the report, an Indigenous girl named Brooklyn was taken into child welfare when she was a baby, and diagnosed with several disorders including fetal alcohol spectrum disorder. A report at age four said she needed a permanent place to call home, but by age six she had lived in 17 foster homes. The report says she did not get the support or permanent housing she needed.

Brooklyn had a history of setting fires. At the time of her death, she had been living in a foster home for 10 weeks. Staff tried to stop her from hanging out with people they believed were criminals by limiting her social media use and screwing her window shut. She would respond to this by barricading her door shut with furniture.

One night, after staff took away her internet access, she became upset. She pushed her mattress against her door and set it on fire. She died from smoke inhalation. Her death was deemed accidental. She was 16.

Trends identified by the panel

The eight Indigenous children were from communities experiencing the effects of colonization, the legacy of residential schools and intergenerational trauma. Child welfare services were “largely unresponsive” to those needs, and did not provide culturally appropriate or trauma-informed approaches.

The Indigenous children came from communities with inadequate homes, undrinkable water and unhealthy food, and they did not have the same access to education, healthcare, social services and recreation as other children. The children didn’t have a safe place to go on reserve, and their homes were deemed unsafe, so they were removed from their communities, disconnecting them from elders, ceremonies and traditions.


All 12 young people weren’t afforded a voice in their own care, and when they tried to say what they needed, they were ignored and shrugged off as “attention seeking.” While all of them suffered from mental illness and developmental issues, their engagement in educational and mental health services was minimal, and never for long periods of time.

On average, they had 12 placements throughout their lives. These placements were based on availability, not whether they were a good fit. And the homes they were placed in were not inspected by the Ministry of Children, Community and Social Services. There is no process to monitor the quality of care provided to these kids. There was also no central database for placements in these homes, making it that much harder to know what homes had space and what quality of care they provided.

Staff and caregivers were poorly trained, lacked capacity and didn’t properly supervise the children. Physical restraints and one-to-one supervision were commonly used, but caregivers didn’t agree on when to use them.

In one case, a 17-year-old named Justin had a disagreement with staff over whether he could ride his bike. As the conflict escalated, staff restrained him. He lost consciousness while in restraint, and was taken to hospital, but never woke up. While his struggle against the restraints contributed to his death, “the manner of death was undetermined,” the report states. The report states that “minimal effort” was made to give Justin the mental health support he needed before his death.


The expert panel recommends the Canadian and Ontario governments immediately provide equitable, culturally relevant services to Indigenous young people and their families.

The panel also calls on Indigenous Affairs and the Ontario ministries responsible for child welfare to identify and provide core support services and an integrated system of care to every child in Ontario. They must also develop a holistic approach to services that supports care until 21 years old. The panel calls for more accountability, and better quality and availability of placements for young people in care.

The panel says many of its recommendations are not new. They have been suggested by experts repeatedly over the last 25 years, but not enough change has happened.

The panel pleads for the government to not ignore its recommendations.

Cover image of Azraya Kokopenace.