Ministry of Community Safety and Correctional Services :: Appendix 1: Project Charter

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The Office of the Chief Coroner’s Death Review of the Youth Suicides at the Pikangikum First Nation

2006 – 2008


Appendix 1. Project Charter

Youth Suicides in Pikangikum 2006 – 2008 - Project Charter

Mission

To review the 16 cases of death by suicide in adolescents on the Pikangikum First Nation from 2006 to 2008 and develop recommendations to prevent deaths in similar circumstances in the future. This project seeks to address, in part, recommendation #1 from the Paediatric Death Review Committee Annual Report June 2009 arising from the review of 9 deaths, “It is recommended that some form of community inquiry focusing on Pikangikum be called to examine:

  1. The understanding and response of the Chief and Council to conditions in the community, which has led to the high rate of suicide.
  2. The role that education, health and other community services could play in preventing the hopelessness, desperation and ultimately, suicide of these young children.
  3. The contributions of community members and natural leaders to the development of strategies to prevent youth suicide.
  4. The community-wide suicide prevention strategies.
  5. The development or results since the Sakanee Inquest into aboriginal youth suicide in 1999.”
Scope
  1. This review will include all youth who died by suicide.
  2. It is anticipated that the youth will be First Nations or Métis youth, but will include any and all youth, irrespective of race.
  3. Only deaths occurring in the years 2006-2008 will be included, but deaths occurring in other years may be referenced.
  4. The deaths examined will be restricted to those youth no younger than 10 years of age, up to, but not including 19 years of age.
  5. The death review will be restricted to deaths occurring in the Pikangikum First Nations Community.
  6. The final report of the deaths will be publicly released.
Early Consultation

The following individuals provided guidance and/or discussed the development of the overarching approach with the Chair:

  1. Grand Chief Stan Beardy, Nishnawbe Aski Nation.
  2. Pikangikum First Nation Council and Band, during a meeting with Dr. David Eden, February 2009.
  3. Dr. David Eden, former Regional Supervising Coroner, North West Region.
  4. Mr. Micheal Hardy, Executive Director, Tikinagan Child and Family Services.
  5. Dr. Richard Meen, Child and First Nations psychiatrist, Kinark Child and Family Services.
  6. Dr. Paul Links, Arthur Sommer Rotenberg Chair in Suicide Studies, Keenan Research Centre, St. Michael’s Hospital, University of Toronto.
  7. Ms. Sabrina Squire, RN, providing primary care to First Nation’s Communities.
  8. Ms. Susan Abell, Child Welfare Consultant and member of the Paediatric Death Review Committee.
  9. Dr. Judy Finlay, Associate Professor, School of Child and Youth Care, Ryerson University; Co-Chair, North-South Partnership for Children and former Provincial Advocate for Children and Youth.
  10. Mr. Irwin Elman, Provincial Advocate for Children and Youth.
  11. Ms. Jeanette Lewis, Executive Director, Ontario Association of Children’s Aid Societies.
  12. Inspector Brad Blair, Ontario Provincial Police (OPP).
  13. Ms. Cathy Paul, Director, Child Welfare Secretariat, Ministry of Children and Youth Services (MCYS).
  14. Ms. Catherine Beamish, Sioux Lookout Law Firm – Native Peoples Law.
  15. Ms. Lori Sterling, Deputy Minister, Ministry of Aboriginal Affairs.
  16. British Columbia Coroners Service, Child Death Review Unit.
  17. Chief Jonah Strang and members of Council in meetings that took place March 6 and 7, 2010.

Objectives

Phase 1

Five distinctive review panels each consisting of members with knowledge, experience and/or expertise in a particular field associated with the focus of their respective review panel will be created.

Part 1: Trip to Pikangikum First Nations/Sioux Lookout: The Chief, Band, Council and Elder’s Panel

  1. A meeting with Chief Jonah Strang, Band, Council and Elders was agreed to by Chief Strang on January 18, 2010. The purpose of the meeting is to determine:
  • Their willingness to participate in the review.
  • Their views on why the deaths are occurring.
  • Their recommendations for solutions to prevent deaths in the future.
  1. Meet with the principal and teachers providing child and youth education from the primary to the high school level to determine:
  • The health education that is provided to the children and youth with respect to suicide from the vantage of prevention, intervention, and post-intervention.
  • Their views on why the deaths are occurring.
  • Their recommendations for solutions to prevent deaths in the future.
  1. Meet with the primary health care team including Mr. Shawn Dookie and Ms. Melanie Turpin, RN’s at Pikangikum Health Centre to discuss:
  • The available resources for the provision of mental health services and addiction services for the youth.
  • The role of Health Canada versus MOHLTC in the provision of these services.
  • Strategies utilized from the health care perspective for prevention, intervention, and post-intervention of youth suicide.
  • Their views on why the deaths are occurring.
  • Their recommendations for the solutions to prevent deaths in the future.
  1. Meet with Tikinagan Child and Family Services Executive Director Mr. Micheal Hardy to discuss:
  • The available resources for the provision of child welfare services including mental health services and addiction services for the children.
  • Strategies utilized from the child welfare perspective for prevention, intervention, and post-intervention of suicide.
  • Their views on why the deaths are occurring.
  • Their recommendations for solutions to prevent deaths in the future.
  1. Meet with the North-South Partnership for Children to determine:
  • Their willingness to utilize their expertise to assist the project.
  • Their recently completed review of the Pikangikum First Nations Community.
  • Their views on why the deaths are occurring.
  • Their recommendations for solutions to prevent deaths in the future.

The current vision for this portion of the project is a three-day trip to the north, including a one-day stay in Sioux Lookout and two days at Pikangikum. It will include Dr. Bert Lauwers, members of the OPP, Ms. Susan Abell, Ms. Karen Bridgman-Acker, a representative from NAN (appointed by Grand Chief Stan Beardy) and a representative from the North-South Partnership, possibly Ms. Linda Nothing-Chaplin.

Part 2: Interview of the Children of Pikangikum by the Child and Youth Advocate’s Team:

The Children’s Panel

The views of the youth of Pikangikum are considered an integral and necessary part of the project and must be properly considered in the final report. For this reason, the Child and Youth Advocate (CYA), whose mandate is to represent the views of youth and advocate of their behalf, was contacted. Utilizing their expertise with respect to youth advocacy, the CYA was asked to investigate the following with respect to a representative group of children from Pikangikum:

  • Their views on why the deaths are occurring.
  • Their recommendations for the solutions to prevent deaths in the future.
  • Any other germane and important representations they wish to make.

The current vision of this portion of the project is that the Child Advocate, Mr. Irwin Elman and/or Ms. Laura Arndt would lead this team.

Part 3: Psychiatry, Child Welfare and Coroner’s Death Review Panel

  1. The Office of the Chief Coroner would utilize its normal investigative tools to acquire the following items for review, where they are available:
  • The Coroner’s Investigation Statement.
  • The Post Mortem Examination Report.
  • The Serious Occurrence Report from the Children’s Aid Society.
  • The Child Fatality Case Summary Report from the Children’s Aid Society.
  • The Internal Review from the Children’s Aid Society.
  • The Paediatric Death Review Committee’s Report(s) of the death.
  • The medical records of the youth.
  • The educational records of the youth.
  • Police Report of the death.
  1. An audit tool will be developed which will capture the demographic characteristics of the youth, their risk factors both modifiable and non-modifiable, and the services which were being provided for the youth, The audit tool will be applied to the documentation obtained for each file, as in 3.1 above, by the members of the Office of the Chief Coroner:
  • Dr. Bert Lauwers,
  • Ms. Karen Bridgman-Acker,
  • Ms. Doris Hildebrandt, and
  • Child Welfare Consultant, Ms. Susan Abell.
  1. A summary will be developed for each of the deaths, and this will be appended to the completed audit tool for presentation to the panel.
  2. The Psychiatry, Child Welfare and Death Review Panel will consist of the following members:
  1. Dr. A. E. Lauwers, Deputy Chief Coroner - Investigations, Chair Paediatric Death Review Committee and Chair, Deaths Under Five Committee, Office of the Chief Coroner
  2. Ms. Doris Hildebrandt, Executive Officer – Investigations, Office of the Chief Coroner
  3. Ms. Karen Bridgman-Acker, Child Welfare Consultant, Office of the Chief Coroner
  4. Ms. Susan Abell, Child Welfare Consultant, member of the Paediatric Death Review Committee
  5. Dr. Paul Links, Arthur Sommer Rotenberg Chair in Suicide Studies, Keenan Research Centre, St. Michael’s Hospital
  6. Dr. Richard Meen, Paediatric Psychiatrist, Kinark Child and Family Services
  7. Dr. Peter Menzies, Centre for Addiction and Mental Health, Aboriginal Services
  8. Ms. Sabrina Squire, RN
  9. Dr. Cornelia Wieman, Department of Public Health Sciences, University of Toronto
  1. The Panel will meet at the Office of the Chief Coroner in Toronto and review each of the deaths, and where appropriate, develop recommendations directed to the avoidance of death in similar circumstances in the future.

Part 4: Social Determinants of Adolescent Mental Health: The Social Determinants Panel

  1. The Office of the Chief Coroner will engage a consultant to generate a paper dedicated to this topic for inclusion in its report. This report will address the following topics:
  1. An overview of the understanding of social determinants of health
  2. A discussion of how this relates to mental health
  3. What social challenges exist in Pikangikum that reflect on adolescent mental health.
  4. Recommendations
  1. Dr. Judy Finlay, School of Child and Youth Care, Ryerson University, and former Provincial Advocate for Children and Youth has agreed to provide this research paper.
  2. The final report will be reviewed and edited by a panel consisting of Dr. Judy Finlay, Dr. Janet Smylie, Dr. Bert Lauwers and Dr. Richard Meen.

Part 5: Providing Child Welfare to First Nations: The Child Welfare Panel

  1. The Office of the Chief Coroner will engage a consultant to generate a paper dedicated to this topic for inclusion in its report. This report will address the following topics:
  1. The challenges of providing child welfare service in the north
  2. The human resource challenges
  3. The fiscal resource challenges
  4. The approach to providing mental health services to the youth of First Nation’s communities from the child welfare perspective
  5. The integration of child welfare and health care in the provision of service to First Nation Youth around issues of addiction and mental health. Non-existent or seamless?
  6. Federal and Provincial responsibilities. Who does what?
  7. Recommendations
  1. Dr. Donald Auger, Executive Director of Anishnabek Family Care, will be asked to generate a paper dedicated to this topic for inclusion in the report.
  2. The final report will be reviewed and edited by a panel consisting of Dr. Donald Auger, Dr. Bert Lauwers, Mr. Micheal Hardy, Ms. Jeanette Lewis, Ms. Karen Bridgman-Acker, Ms. Sabrina Squire and Dr. Cornelia Wieman.
Phase 2

A draft report of the collaborative findings, conclusions and recommendations of each of the 5 review panels will be produced and distributed to Stakeholders for their comments and feedback. Revisions based on the feedback and comments will be distributed and the report will be finalized when a consensus on content is reached by the Stakeholders and review panel members.

The following Stakeholders have been identified:

  1. Association of Native Child and Family Service Agencies of Ontario (ANCFSAO)
  2. Catherine Beamish, Sioux Lookout Law Firm – Native Peoples Law
  3. Dr. Tom Dignan
  4. Health Canada
  5. Indian and Northern Affairs Canada (INAC)
  6. Local Health Integration Network
  7. Ministry of Aboriginal Affairs (MAA)
  8. Ministry of Children and Youth Services (MCYS)
  9. Ministry of Community Safety and Correctional Services (MCSCS)
  10. Ministry of Health and Long-Term Care (MOHLTC)
  11. Nishnawbe Aski Nation (NAN)
  12. Ontario Association of Children’s Aid Societies (OACAS)
  13. Ontario Provincial Police (OPP)
  14. Pikangikum First Nation Band
  15. Tikinagan Child and Family Services
Phase 3

The Chair is responsible for the final report. The final report will be released by the Office of the Chief Coroner to the public and available electronically. It is anticipated that a press conference will take place.

Project Participants

  1. Dr. A. E. Lauwers, Deputy Chief Coroner
  2. Ms. Karen Bridgman-Acker, Office of the Chief Coroner
  3. Ms. Doris Hildebrandt, Office of the Chief Coroner
  4. Ms. Susan Abell, Child Welfare Consultant, Member, Paediatric Death Review Committee
  5. Dr. Donald Auger, Anishnabek Family Care
  6. Ms. Rowena Cruz, Office of the Chief Coroner
  7. Mr. Irwin Elman, Office of the Provincial Advocate for Children and Youth
  8. Dr. Judy Finlay, School of Child and Youth Care, Ryerson University
  9. Mr. Micheal Hardy, Tikinagan Child and Family Services
  10. Ms. Jeanette Lewis, Ontario Association of Children’s Aid Societies
  11. Dr. Paul Links, Keenan Research Centre, St. Michaels Hospital
  12. Dr. Richard Meen, Kinark Child and Family Services
  13. Dr. Peter Menzies, Centre for Addiction and Mental Health, Aboriginal Services
  14. Ms. Linda Nothing-Chaplin, North-South Partnership for Children
  15. Dr. Janet Smylie, Keenan Research Centre, St. Michael’s Hospital
  16. Ms. Sabrina Squire, RN
  17. Dr. Cornelia Wieman, Department of Public Health Sciences, University of Toronto

Assumptions

  1. All participants will accept direction from the Chair.
  2. All participants understand the process and reasoning for the “review panel” approach as opposed to a Coroner’s Inquest into the Pikangikum suicide deaths.
  3. All participants will provide their individual professional expertise and be willing to compromise where necessary to develop a consensus on recommendations regarding adolescent suicide in the Pikangikum First Nation.
  4. The Stakeholders, as listed below, will be receptive to receiving the report and understand its intention.
  5. The report will be of value to all First Nation Communities and Public Health agencies across Ontario in providing mental health care to children and youth.
  6. The Chair will review and edit all aspects of the final report.

Benefits

  1. The “review panel” process negates the lengthy time scheduling delays (years) and significantly increased cost of a Coroner’s Inquest, which would likely be months in duration.
  2. The “review panel” process is not performed in a public forum, therefore, ongoing media scrutiny, public and/or political response would not be divergent factors and would allow participants to remain focused and free to exercise the mandate of the review.
  3. The Stakeholders will have a concrete “third party” report to reference when developing Pikangikum First Nation children and youth programs, and specifically, directing resources focused on youth mental health.
  4. The report will be a reference source not only for the Stakeholders, but all health providers across Ontario as well as other professional organizations and associations in creating, developing and implementing programs directed at child and adolescent mental health and suicide prevention.
  5. The findings and recommendations of the report, if acted upon, may prevent deaths of adolescents and youths in both the Pikangikum First Nation and in similar circumstances in the future.
 

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