Investigations and Child Death Reviews

When any child, youth, or young adult up to age 21 dies in Manitoba, the Office of the Chief Medical Examiner (OCME) officially notifies the Manitoba Advocate for Children and Youth (Manitoba Advocate). If the child or their family had received any reviewable service (child welfare) within 12 months of the death of the child, the Manitoba Advocate may review and investigate the public services that were delivered to the child and their family. The purpose of the reviews and investigations is to examine the effectiveness and responsiveness of the services provided to the child and their family.

According to legislation, the purpose of an investigation by the Manitoba Advocate is to determine:

    • if a public service, or its policies or practices, might have contributed to the child’s death,

    • if the death was due to any circumstance described in s.17 of The Child and Family Services Act (child in need of protection),

    • if the death occurred in unusual or suspicious circumstances, or

    • if the death was due to suicide or homicide.

The focuses of our investigations are to identify whether programs and services that were or should have been provided can be improved to enhance the safety and well-being of all children, youth, and young adults in Manitoba, and to reduce the likelihood of a future death in similar circumstances.

If the Manitoba Advocate opens a review or investigation following the death of a child, our team of Investigators will collect and analyze information from service systems that may have provided services to the family, including reviewable services (child welfare and designated services), adoption, disabilities, education, mental health, addiction, victim support, and youth justice.

In addition, we may collect information from other relevant sources such as police reports, fire commissioner reports, medical records, and more. Our legislation allows the Manitoba Advocate to require a public body or other person to provide any information in its custody or under its control – including personal health information – necessary to enable the Manitoba Advocate to carry out a review or investigation. Public bodies have a legal duty to comply with information requests from the Manitoba Advocate.

The investigative process includes opportunities for feedback and dialogue with various groups and individuals, including professionals who provide services to children and families.

Our reports examine public service delivery to Manitoba families through the eyes of the deceased child and we invite and encourage family and community participation. Whenever possible, our investigators travel to the home community of the child, youth, or young adult, to speak with people who knew and loved the child, in order to gain a better understanding of how services are delivered within a local community context.

The Manitoba Advocate may choose to publicly release results of any review or investigation through a Special Report, as described in section 31 of The Advocate for Children and Youth Act.

Under the new legislation, MACY is also responsible for monitoring the levels of compliance that public systems demonstrate with the recommendations made by our office. The Manitoba Advocate has determined that this information will be shared with the public on our website and through our annual report.