Investigations and Child Death Reviews

When any child, youth, or young adult (young person) up to age 21 dies in Manitoba, the Office of the Chief Medical Examiner (OCME) notifies the Manitoba Advocate for Children and Youth (Manitoba Advocate). If the young person or their family received any reviewable service (child welfare, youth addiction, youth mental health, or youth justice) within 12 months preceding their death, the Manitoba Advocate may review the public services delivered to the young person and their family.

Image showing the process of child death notifications from start to end

Child death reviews are a unique form of advocacy undertaken by the Manitoba Advocate. Investigators become the voice of the young person, ensuring their rights under the United Nations Convention on the Rights of the Child (UNCRC) are upheld. Our focus during the child death review is to determine if the services delivered matched the needs of the young person and their family. Investigators note recurring circumstances and trends and identify gaps in services that may have improved a young person’s life. Through this work our office strives to enhance the effectiveness and responsiveness of public services and to inform public policies as they relate to young people in Manitoba.

If questions remain after the child death review, the Manitoba Advocate may decide a more comprehensive investigation of the services provided to the young person and their family is required.  When the Manitoba Advocate opens an investigation, a team of Investigators collect and conduct an extensive analysis of information from designated services who were involved with the young person and their family, including: child welfare, adoption, disabilities, education, youth mental health, youth addiction, victim support, and youth justice. We may collect additional information from, but not limited to, local law enforcement, the fire commissioner, or access medical records. The Manitoba Advocate is the only body within Manitoba with the ability to investigate services provided to the young person and their family from all designated service domains. This provides the Manitoba Advocate the unique ability to understand how designated services interacted to impact each young person’s life.

Our reports examine public service delivery to Manitoba families through the eyes of the young person and the Manitoba Advocate invites and encourages family and community participation. Whenever possible our investigators travel to the home community of the young person to speak with people who knew and loved the young person and to gain a better understanding of how services are delivered within the local community context. The investigative process allows for collaboration with families, public bodies, subject matter experts, and the larger community, as they possess expertise regarding issues impacting young people. Once information from all sources is collected and analyzed, the Manitoba Advocate generates thoughtful findings and recommendations. The focus of an investigation is not to assign blame, but to identify where programs and services could act to enhance the safety and well-being of young people and to reduce the likelihood of future deaths in similar circumstances.

The results of the investigation may inform a public Special Report under Part 5 of The Advocate for Children and Youth Act (ACYA). Since 2018, the Manitoba Advocate has been responsible for monitoring recommendation compliance by public systems. This information is available on our website and through our annual report.