Special Reports

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INNAGAKEYAA BIMADIZEWIN (TOWARDS THE GOOD LIFE): UNIFYING VOICES FOR YOUTH ADDICTION SYSTEM CHANGE

This special report amplifies the voices of young people who use substances and have first-hand experience with the youth addiction system, as well as the profound insights of those service providers working tirelessly to support them. Taken together, the views, expertise, and experiences contained within this special report shed insight on some of the current problems within the youth addiction system, as well as possibilities for transforming it to better serve the children and youth it is intended for.

We thank the youth and service providers who generously shared their time and their experiences with us. This report would not have been possible without their important contributions.

Read the report in English (PDF)

SHIFTING THE LENS: UNDERSTANDING AND CONFRONTING INEQUITIES IN SLEEP-RELATED INFANT DEATHS IN MANITOBA

Shifting the Lens: Understanding and Confronting Inequities in Sleep-Related Infant Deaths in Manitoba is a re-framed follow-up to the 2020 Special Report titled, Safe and Sound: A Special Report on the Unexpected Sleep-Related Deaths of 145 Manitoba Infants. This report highlights the increased responsibility governments hold in preventing sleep-related tragedies. The findings reveal how social and structural factors hold strong associations to an infant’s ability to flourish, and the report discusses the larger widespread issues persisting in Manitoba.

Through collaboration with government departments, the Manitoba Advocate has re-issued some of the Safe Sleep recommendations released in 2020 through Safe and Sound. The Manitoba Advocate also issued one new recommendation, calling on the Government of Manitoba to improve the social determinants of health for all Manitobans.

Read the report in English (PDF)

Lisez le rapport en francais (PDF)

MOVING THE DIAL ON CHILDREN’S RIGHTS IN MANITOBA: SUMMARY ASSESSMENT OF GOVERNMENT COMPLIANCE WITH RECOMMENDATIONS MADE UNDER THE ADVOCATE FOR CHILDREN AND YOUTH ACT.

This special report provides information on the progress made by the Manitoba government in implementing the 80 recommendations issued by the Manitoba Advocate for Children and Youth since The Advocate for Children and Youth Act came into effect on March 15, 2018.

Ce rapport spécial fourni de l’information sur la suite donnée aux 80 recommandations que la protectrice du Manitoba a adressées au gouvernement de la province depuis l’entrée en vigueur de la Loi sur le protecteur des enfants et des jeunes le 15 mars 2018.

Read the Compliance Report (PDF) in English

Lisez le rapport en francais (PDF) in French.

Read the supplemental content (PDF) (appendix) – Lisez l’annexe de renseignements supplémentaires (en anglais).

Read the press release in English here (PDF).

Read the press release in French here (PDF).

MEMENGWAA WIIDOODAAGEWIN (BUTTERFLY PROJECT): MANITOBA ADVOCATE RELEASES A SPECIAL REPORT TO HONOUR EISHIA HUDSON

The Manitoba Advocate for Children and Youth (MACY) released Memengwaa Wiidoodaagewin (Butterfly Project), a special report in honour of Eishia Hudson, who died as a result of a gunshot wound inflicted by a member of the Winnipeg Police Service on April 8, 2020. Empowered by The Advocate for Children and Youth Act (ACYA), the report assesses the public services that were received by Eishia and her family prior to her death with the goal of increasing the effectiveness and responsiveness of those services, while also honouring Eishia’s story.

Based on a detailed review and analysis of the provincial public services provided to Eishia and the individual-, family-, and community-level environments involved in her life, the Manitoba Advocate is making four findings and issuing four recommendations.

Read Memengwaa Wiidoodaagewin (Butterfly Project) here. (Single page PDF)

Lisez le rapport en francais (PDF)

Read Memengwaa Wiidoodaagewin (Butterfly Project) here. (Online reader PDF)

Read the press release in English here. (PDF)

Read the press release in French here. (PDF)

RIGHTS DELAYED ARE RIGHTS DENIED. SUMMARY ASSESSMENT OF GOVERNMENT COMPLIANCE WITH RECOMMENDATIONS MADE UNDER THE ADVOCATE FOR CHILDREN AND YOUTH ACT

This special report provides Manitobans with information on the Manitoba government’s compliance with 67 recommendations that the Manitoba Advocate has made since The Advocate for Children and Youth Act came into effect on March 15, 2018, and until December 31, 2021.

Ce rapport spécial informe la population du Manitoba sur la suite donnée aux 67 recommandations que la protectrice du Manitoba a adressées au gouvernement de la province depuis l’entrée en vigueur de la Loi sur le protecteur des enfants et des jeunes le 15 mars 2018, jusqu’au 31 décembre 2021.

Read the report (PDF)

Lisez le rapport en francais (PDF)

Read the English media release (PDF) – Lisez le communiqué en anglais

Read the French media release (PDF) – Lisez le communiqué en français

Read the executive summary (PDF) – Lisez le résumé

Read the handbook for Compliance Assessment of MACY Recommendations (PDF) – Lisez le manuel d’évaluation de la suite donnée aux recommandations du PEJM (en anglais)

Read the supplemental content (PDF) (appendix) – Lisez l’annexe de renseignements supplémentaires (en anglais)

EVERY TWO HOURS: A SPECIAL REPORT ON CHILDREN AND YOUTH EXPOSED TO INTIMATE PARTNER VIOLENCE IN MANITOBA

In Manitoba, a child is exposed to a police-reported incident of intimate partner violence (IPV) every two hours. Exposure to IPV in childhood can be deeply traumatic for young people, shattering feelings of safety, leading to lifelong mental health challenges, and sometimes reinforcing cycles of intergenerational violence.

This special report, the first of its kind, follows 671 Manitoba children and youth exposed to IPV in April 2019 in order to understand their pathways through service responses from police, Victim Services, and Child and Family Services. The report repositions children exposed to IPV as centrally-impacted victims with rights to services. Informed by the voices of experiential young people, the Elders Council, and service providers, the special report contains seven recommendations to improve the effectiveness and responsiveness of services for children, youth, and families in Manitoba.

« TOUTES LES DEUX HEURES » : LA PROTECTRICE DU MANITOBA PUBLIE LE TOUT PREMIER RAPPORT SUR LES ENFANTS EXPOSÉS À LA VIOLENCE ENTRE PARTENAIRES INTIMES

Au Manitoba, toutes les deux heures, un enfant est exposé à un incident de violence entre partenaires intimes (VPI) rapporté par la police. L’exposition à la VPI pendant l’enfance peut être profondément traumatisante pour les jeunes, dévastatrice pour leur sentiment de sécurité et à l’origine de problèmes durables de santé mentale, et elle renforce parfois les cycles de violence intergénérationnelle.

Premier de son genre, ce rapport spécial suit 671 enfants et jeunes du Manitoba ayant été exposés à la VPI en avril 2019 pour nous permettre de comprendre les réponses qu’ils ont obtenues de la police, des Services aux victimes et des Services à l’enfant et à la famille. Le rapport replace les enfants exposés à la VPI de façon à les considérer comme des victimes principales qui ont droit à des services. À la lumière des commentaires recueillis auprès des jeunes ayant vécu ce genre de situation, auprès du Conseil des aînés et des fournisseurs de services, le rapport spécial propose sept recommandations pour améliorer l’efficacité et la réponse des services destinés aux enfants, aux jeunes et aux familles du Manitoba.

KIDS CAN’T KEEP WAITING: SUMMARY ASSESSMENT OF GOVERNMENT COMPLIANCE WITH RECOMMENDATIONS MADE UNDER THE ADVOCATE FOR CHILDREN AND YOUTH ACT

This special report provides Manitobans with information on the Manitoba government’s compliance with 51 recommendations that the Manitoba Advocate has made since The Advocate for Children and Youth Act came into effect on March 15, 2018, and until December 31, 2020.

Ce rapport spécial informe la population du Manitoba sur la suite donnée aux 51 recommandations que la protectrice du Manitoba a adressées au gouvernement de la province depuis l’entrée en vigueur de la Loi sur le protecteur des enfants et des jeunes le 15 mars 2018, jusqu’au 31 décembre 2020.

Read the report (PDF) – Lisez le rapport (en anglais)

Read the English news release (PDF) – Lisez le communiqué en anglais

Read the French news release (PDF) – Lisez le communiqué en Français

Read the French executive summary (PDF) – Lisez le résumé en Français

Read the handbook for Compliance Assessment of MACY Recommendations (PDF) – Lisez le manuel d’évaluation de la suite donnée aux recommandations du PEJM (en anglais)

Read the supplemental content (PDF) (appendix) – Lisez l’annexe de renseignements supplémentaires (en anglais)

FINDING THE WAY BACK: AN AGGREGATE INVESTIGATION OF 45 BOYS WHO DIED BY HOMICIDE OR SUICIDE IN MANITOBA.

Too often unseen, boys in Manitoba need our attention. As a follow-up to a 2020 investigation focused on the suicide deaths of girls, the Manitoba Advocate set out to see what common issues exist among boys in Manitoba who are at risk of suicide or homicide and what systemic improvements can be made to help young men, particularly those who are First Nations, Metis, or Inuit. Of the 45 boys with experience in the child welfare system who died by either suicide or homicide and whose stories inspired this special report, 78% were identified as First Nations youth and 49% lived in northern Manitoba.

Guided by the office’s Knowledge Keeper and Elders Council, the Manitoba Advocate combined investigative and qualitative research approaches in the drafting of this report. Together with Dr. Marlyn Bennett, an Indigenous scholar and professor at the University of Manitoba, the office also held a digital storytelling workshop with two First Nations young men, Michael Breland and Trevor Merasty. They created a music video being released alongside the report, which details some of their lived experiences. In accordance with her authority under The Advocate for Children and Youth Act, and in alignment with Calls to Action from the national Truth and Reconciliation Commission, the Manitoba Advocate is making four recommendations in this report to improve the effectiveness and responsiveness of child welfare, education, and youth justice services in Manitoba.

Read the report (PDF)

Lire le message de la Protectrice (PDF) en français

Read the (PDF) news release

Watch the music video

THE RIGHT TO BE HEARD: A SPECIAL REPORT ON THE MANITOBA ADVOCATE FOR CHILDREN AND YOUTH’S YOUTH LISTENING TOUR, 2021

The Right to Be Heard is a special report featuring the thoughts and opinions of hundreds of Manitoba youth who discussed community issues and proposed solutions for a better future. The findings come from a province-wide Youth Listening Tour and online survey, which were hosted by staff from the Manitoba Advocate for Children and Youth (MACY) in 2020. The purpose of the Youth Listening Tour was to raise awareness of children’s rights while also gathering information about the challenges, priorities, and solutions youth identify in their communities and beyond.

Youth raised a variety of diverse, but often related issues they face in their communities, including substance use, mental health and well being, poverty, violence, and racism and discrimination. Overwhelmingly, youth spoke about the need for more investments in accessible mental health and addictions programs and the need for more recreational activities that provide healthy opportunities and community belonging.

This special report presents governments and decision-makers in Manitoba with the opportunity to hear the voices of youth and let these contributions guide them to make informed decisions about their strategic priorities and funding.

We are always here to listen. If you are a youth that did not get a chance to participate in the Listening Tour and would like to share your thoughts, please take our survey.

Read the Report (PDF)

Lire les messages (PDF) en français

Read the news release (PDF)

BRIDGING THE GAPS: ACHIEVING SUBSTANTIVE EQUALITY FOR CHILDREN WITH DISABILITIES IN MANITOBA

Bridging the Gaps: Achieving Substantive Equality for Children with Disabilities in Manitoba is a special report stemming from a child death investigation and broader systemic research. The Manitoba Advocate was notified of the death of Emma* in 2017. Emma’s family struggled to navigate disability services in Manitoba and ultimately relied on Child and Family Services for support. Emma died accidentally, just days before an emergency systems meeting was scheduled to discuss an out-of-home placement for her.

In addition to Emma’s investigation, MACY includes findings from a survey of caregivers of children and youth with disabilities; interviews with academic experts, current and former service providers, families, and children and youth with disabilities; and extensive data analysis of Children’s disABILITY Services (CdS) and Child and Family Services (CFS) records. Over 400 people were consulted in the making of this report. The Manitoba Advocate makes nine recommendations to the provincial government and service providers for system improvements.

*Name has been changed.

French reports available upon request/Rapports en francais disponsible sur demande.

STILL WAITING – INVESTIGATING CHILD MALTREATMENT AFTER THE PHOENIX SINCLAIR INQUIRY

Phoenix Sinclair would have turned 21 years old this year. Fifteen years after her death and seven years after the release of the public inquiry into her death, major changes have occurred in the child welfare system. Yet, we are still waiting for the system to consistently support families to keep children safe.

What you will read in this special report is that while large-scale change has occurred and continues to unfold, the needs of children and youth are not always prioritized and consistent and equitable services remain out-of-reach for too many families. Despite the massive public inquiry into Phoenix Sinclair’s death and the 62 recommendations that were made from that evidence, children are still dying of maltreatment similar to what Phoenix experienced. For example, between 2008 and 2020, there were 19 Manitoba children under the age of five who were maltreated and died. Their lives inspired this special report and five recommendations from the Advocate for policy improvements.

French reports available upon request/Rapports en francais disponsible sur demande.

Read the full report (PDF)

Read the fact sheet (PDF)

Read the news release (PDF)

ARE THEY LISTENING? SUMMARY OF GOVERNMENT COMPLIANCE WITH RECOMMENDATIONS ISSUED UNDER THE ADVOCATE FOR CHILDREN AND YOUTH ACT.

This special report provides Manitobans with information on the Manitoba government’s compliance with 23 recommendations that the Manitoba Advocate has made since the new Act came into effect on March 15, 2018, and until December 31, 2019.

Click here to read the full report (PDF)

Click here to read the news release (PDF)

Click here to see the handbook for Compliance Assessment of MACY Recommendations (PDF)

“STOP GIVING ME A NUMBER AND START GIVING ME A PERSON”: HOW 22 GIRLS ILLUMINATE THE CRACKS IN THE MANITOBA YOUTH MENTAL HEALTH AND ADDICTION SYSTEM (2020)

Mental health and addictions issues affect Manitoba children and youth at soaring rates and, for years, demand for these health services has outpaced supply. In the last five years, suicide has become the leading manner of death for Manitoba youth ages 10-17. This special report dives into lessons learned from the suicide deaths of 22 Manitoba girls. The girls, ages 11-17, were primarily from rural and northern Manitoba communities and died between 2013 and 2019. Their struggles point to glaring cracks in provincial mental health and addiction services. The Advocate makes seven recommendations to the provincial government about how to fix these systems and therefore improve the wellbeing of Manitoba children and youth.

Click here to read the full report (PDF)

To read the news release, click here (PDF)

To read the Manitoba Advocate’s remarks click here (PDF)

SAFE AND SOUND: A SPECIAL REPORT ON THE UNEXPECTED SLEEP-RELATED DEATHS OF 145 MANITOBA INFANTS

In Canada, sudden and unexplained deaths remain the second leading cause of death for infants between the ages of one and 12 months. Sleep-related infant deaths are a not only a serious public health concern, but they are also a children’s rights issue. This report addresses the extent and nature of unsafe sleep-related deaths in Manitoba, examines the barriers and gaps that prevent the reduction of known risk factors, and makes 13 targeted recommendations to increase the effectiveness and responsiveness of services for infants and their families. What you will read in this report is a clear message of hope: unsafe sleep-related deaths can be reduced in our province by addressing the known risk factors. Most sleep-related infant deaths can be prevented by reducing the known risk factors and by placing the infant alone, on their back, and in a crib for every sleep.

Click here to read full report (PDF)

Click here to read the Safe Sleep Pamphlet (PDF)

Click here for the Safe Sleep Infographic (PDF)

THE SLOW DISAPPEARANCE OF MATTHEW A FAMILY’S FIGHT FOR YOUTH MENTAL HEALTH CARE IN THE WAKE OF BULLYING AND MENTAL ILLNESS (2020)

Matthew’s story is one of a family desperate to save their son. Matthew’s six-year struggle with depression, anxiety, substance use, and persistent thoughts of suicide consumed the family. Over time, his mother lived with the fear that something would happen if she was not able to provide round-the-clock supervision and support to Matthew. It was clear to the family that the patchwork of mental health interventions being offered were not well-coordinated and were not actually helping her son to recover. Matthew had many contacts with community supports, including school-based and community-based psychologists, psychiatrists, public and private therapists, occupational therapists, doctors (his pediatrician, as well as during in-patient treatment and emergency crises), police officers, paramedics, mobile crisis teams, and CFS staff. Still, Matthew’s family had no success in getting him long-term help.

Click here to read full report (PDF)

A PLACE WHERE IT FEELS LIKE HOME: THE STORY OF TINA FONTAINE (2019)

Tina Fontaine might always be known for the tragic way in which she died, but it is her life that is an important story worth knowing.

It was on August 17, 2014, when most people would learn her name, but Tina’s story began long before that day. It began even before Tina was born on New Year’s Day in 1999.

To know Tina’s story, to really understand how she came to symbolize a churning anger of a nation enraged, each of us can look as far back as the arrival of European settlers, and as close to home as the depth of our own involvement or indifference in the lives and experiences of Indigenous youth.

IN NEED OF PROTECTION: ANGEL’S STORY (2018)

The Manitoba Advocate for Children and Youth today released her second public child death report since the expansion of her mandate earlier this year. Today’s report, In Need of Protection: Angel’s Story details the life of Angel, who died at age 17 after a lifetime of unaddressed and compounded trauma. The Manitoba Advocate discusses themes of Adverse Childhood Experiences (ACEs), sexual exploitation of children and youth, the urgent need for a continuum of care including safe and secure addiction treatment for youth, and further calls on the provincial government to implement a robust youth mental health strategy, which is so desperately needed. The Advocate’s report links what happened to Angel to what is happening today for a number of youth who are connected to the advocacy program at the Manitoba Advocate for Children and Youth office.

Click here to read full report (PDF)

Manitoba Advocate remarks (PDF)

DOCUMENTING THE DECLINE: THE DANGEROUS SPACE BETWEEN GOOD INTENTIONS AND MEANINGFUL INTERVENTIONS (2018)

In her first publicly released child death investigation since the proclamation of The Advocate for Children and Youth Act in March 2018, Manitoba Advocate for Children and Youth, Daphne Penrose, shares the story of an Indigenous youth who died tragically in a vehicle accident in a rural community.

Click here to read full report (PDF)