Findings from the Ontario Paediatric Death Review Committee

Findings from the Ontario Paediatric Death Review Committee & Deaths Under 5 Committee Smart Risk Learning Series Karen Bridgman-Acker, MSW, RSW August 2009

Motto of the Office of the Chief Coroner: “We speak for the dead to protect the living”

Learning Objectives n Overview of the Committees n Deaths Reviewed by PDRC in 2008 n Deaths Under 5 Committee Reviews in 2008 n Themes and Trends: u Unsafe Sleeping u Accidental Fire Deaths u Adolescent Suicide n Case Examples n Key Messages for Prevention of Future Deaths

The Office of the Chief Coroner for the Province of Ontario n n Medical Coroner’s System Ø 1 Chief, 2 Deputy Chiefs, 9 Regional Supervising Coroners, approximately 320 Coroners Ø Chief Forensic Pathologist Ø Regional Forensic Pathology Centres Ø Part of the Ministry of Community Safety and Correctional Services 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 n Parallel Investigations: n Coroner n Police n Children’s Aid Society

Joint Directive: MCYS and OCC n n n n (2006) Criteria for reporting and reviewing Child Welfare deaths Roles and responsibilities Timelines Coordination of Child Welfare death reviews Internal child death review guidelines Analysis of Child Welfare deaths Tracking of trends, themes, statistics and recommendations Annual report production and dissemination

In reviewing child deaths, we all learn from: n n n Investigations Internal Reviews Death Review Committees Inquests Sharing results & recommendations “Mistakes are a great educator when one is honest enough to admit them and willing to learn from them” (anonymous)

IMPORTANCE OF INTERNAL and PDRC DEATH REVIEWS ü ü ü Objective, “second set of eyes” (quality assurance) Transparency Identify and track themes, trends, patterns Contribute to collection of data, research Learn from errors or omissions to prevent future deaths Disseminate results to improve outcomes

Context of Paediatric Deaths in Ontario (0 -19) Manner NATURAL 2003 220 2004 231 2005 218 2006 212 2007* 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 *NB: Preliminary data for 2007 • 45% OCC • 17% CAS

Reporting and Review of Children’s Deaths (0 -19) n Manner of Deaths reviewed: Natural, Accident, Suicide, Homicide and Undetermined n Deaths of children investigated by the Office of the Chief Coroner of Ontario – average 598 per year (2003 -2006) n Deaths of children reported by a CAS – average 93 (15. 5%) per year (2006 -2008) n Deaths reviewed by PDRC under the Joint Directive – average 78 per year since 2006

PDRC and DU 5 C Ø Members with special expertise Ø 2 of 7 multi-disciplinary expert committees at OCC Ø 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 Ø 10 meetings per year; report and recommendations disseminated to the Agency, Coroner, Ministry Ø Annual Report released publicly in June Ø DU 5 C reviews all deaths of children under the age of 5 and classifies COD and MOD

PDRC Purpose 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 u u u 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

Committee Membership Ø Coroners Ø Child Welfare experts Ø Paediatricians (community & hospital) Ø Other physicians (i. e. Sick Kids, Mc. Master and London Children’s Hospitals) Ø Police detectives Ø Crown Attorney

What is Reviewed? Coroner’s Investigation report n CAS Internal Review n CAS records if necessary n Police report n Medical records and post-mortem results n

Annual Child Death Reviews PDRC Medical: 25 CAS: 60 – 70 DU 5 C 150 - 200 Not all deaths can be reviewed in the year of death because of: Øvolume Øcriminal charges Øincomplete investigation

Preventable Deaths n Many of the 42 deaths reviewed in 2008 might have been prevented. n 2008 PDRC and Internal Child Death Reviews illustrate that future deaths can be avoided by: u Provision of safer sleep environments. u u u 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 the future

2008 Reviews by Manner of Death (42)

Findings: Most High-Risk, Vulnerable Groups ØInfants under 12 months Ø Youth between 12 and 18 years

INFANTS Emerging Trends: Ø Decrease in the # of SIDS classifications Ø Increase in the # of SUDI classifications Ø Enhanced awareness of unsafe sleeping (adult bed, couch, crib with extra bedding, pillows, toys) and bed -sharing as contributing factors Ø 35% of cases reviewed at PDRC are infants < 1 year Ø 42% of DU 5 C cases involve unsafe sleeping situations

DEATHS UNDER 5 REVIEWS in 2008 n n n 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.

DU 5 C 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 n n n 1999 – U. S. Consumer Product Safety Commission 1999 – American Medical Association 1992/2000/2005 – American Academy of Pediatrics 2004 - U. K. Department of Health 2004 – Canadian Paediatric Society 2007/2008 PDRC Annual Reports n n 2007 – U. S. National SIDS and Infant Death Program 2007 – Canadian Foundation for the Study of Infant Death Michigan Fetal Infant Mortality Review Network (FIMR) 2008 - Health Canada Consumer Product Safety

Case Example - Undetermined n n n 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 sleeping environments.

Possible future directions… n Public Education n Community Collaboration n Training and Speciality n Research

Example of a Public Education Initiative

Collaboration n Joint Protocols for investigation, reporting and reviewing child deaths n Information sharing n Case conferences with all investigators

Training and Specialty OACAS training – At Risk Infants n OCC training – Child Deaths n High Risk Infant Protocols/Policies n Infant Specialists n Adolescent training and programs n

Research: Paediatric Accidental Residential Fire Deaths in Ontario Amy Chen, K. Bridgman-Acker, J. Edwards n Retrospective review of all accidental residential fire deaths of children<16

Findings n n n 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 n “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. n 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. n They have less supervision, and are more likely to be exposed to smokers in the house and display fire-playing behaviour. n Interestingly, in our data set, 7 out of 12 children who died as a result of fire-play had a history of CAS involvement. n 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. n 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 n 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. n 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. n 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. n 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 noncompliance should be reported to the Fire Marshal’s Office for further investigation and subsequent resolution.

Case Example: Accident n 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 abuse. n Cause of Death: Smoke inhalation n Manner of Death: Accident n 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 Fire Death

Case Example: Homicide 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. n 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. n Cause of Death: Asphyxia from hanging n Manner of Death: Suicide n 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 vehicle collisions. n 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. n (Centre for Suicide Prevention, Calgary, Alberta).

Lessons Learned - Themes • Infants and youth comprise very vulnerable subsets of children needing protection services. • Prevention initiatives directed at reducing unsafe sleeping, suicide and fire deaths are required more than ever. • Issues facing 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 provincial standards. • 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.

Key Messages • 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 mattress. • 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. n Many, if not most, tragedies can be prevented. Let’s continue to work together to decrease the risk of injury and death. n