OCC Inquests - Sampson 2016

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Sampson
Given Name(s): Katelynn Angel
Age: 7

Held at: 25 Morton Shulman Avenue, Toronto
From: November 9th
To: November 29th, 2017
By: Dr. William Lucas, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Katelynn Angel Sampson
Date and time of death: August 3rd, 2008 at 3:04 a.m.
Place of death: 105 Westlodge Avenue, Apartment #210, Toronto, Ontario
Cause of death: Complications from multiple blut force injuries
By what means: Homicide

(Original signed by: Foreperson)


The verdict was received on the 29 of November, 2017
Coroner's name: Dr. William Lucas
(Original signed by coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Katelynn Angel Sampson


Jury Recommendations

  1. That all parties to this inquest ensure that Katelynn’s Principle applies to all services, policies, legislation and decision-making that affects children.

Katelynn’s Principle

The child must be at the centre, where they are the subject of or receiving services through the child welfare, justice and education systems.

A child is an individual with rights:

  • who must always be seen
  • whose voice must be heard
  • who must be listened to and respected

A child’s cultural heritage must be taken into consideration and respected, particularly in blended families.

Actions must be taken to ensure the child who is capable of forming his or her own views is able to express those views freely and safely about matters affecting them.

A child’s view must be given due weight in accordance with the age and maturity of the child.

A child should be at the forefront of all service-related decision-making.

According to their age or maturity, each child should be given the opportunity to participate directly or through a support person or representative before any decisions affecting them are made.

According to their age or maturity, each child should be engaged through an honest and respectful dialogue about how/why decisions were or will be made.

Everyone who provides services to children or services that affect children are child advocates. Advocacy may potentially be a child’s lifeline. It must occur from the point of first contact and on a continual/continuous basis thereafter.

Premier of Ontario

  1. The Premier of Ontario champion the implementation of the United Nations Convention on the Rights of the Child (UNCRC), to afford children and youth their rights under the UNCRC, and in particular, to recognize that children are individuals with rights, whose voices must be heard on matters affecting them, and their views must be given due weight in accordance with the age and maturity of the child.

Government of Ontario, Ministry of Children and Youth Services, Ministry of Education, Ministry of the Attorney General, Family Rules Committee, Ontario Association of Children’s Aid Societies, Association of Native child and Family Services Agencies of Ontario and Children’s Aid Societes of Ontario.

  1. The Government of Ontario, Ministry of Children and Youth Services, Ministry of Education, Ministry of the Attorney General, Family Rules Committee, Ontario Association of Children’s Aid Societies, Association of Native Child and Family Services Agencies of Ontario and Children’s Aid Societies of Ontario implement a Child Rights Impact Assessment process for future reviews of legislation, regulations, directives, policies and procedures, to screen for the impact on children's rights.

Government of Ontario

  1. The Government of Ontario consider offering a "Duty to Report" course (for example, online) for all Ontario Public Servants to show its commitment to public education on the importance of the "Duty to Report".

Ministry of Children and Youth Services (MCYS)

"Duty to Report"

  1. The Ministry of Children and Youth Services review and consider raising the financial penalties in the Child and Family Services Act where a professional with knowledge of child abuse fails to report pursuant to s.72(1), and extend the penalty to the professional's employer when the individual was acting in their (official or employment) capacity and failed to report.
  2. The Ministry of Children and Youth Services fund and carry-out a comprehensive, ongoing, public awareness campaign on the "Duty to Report". This campaign should reflect Ontario's cultural diversity as well as the experience of indigenous communities. In addition, there should be positive messaging around the work of Children’s Aid Societies in Ontario.
  3. The Ministry of Children and Youth Services consider revising the Child and Family Services Act to include penalties for non-professionals who have knowledge of child abuse and fail to exercise their "Duty to Report" as citizens.
  4. The Ministry of Children and Youth Services establish a mandatory annual training program for those professionals with a higher responsibility surrounding the duty to report under s. 72.1(5) of the Child and Family Services Act.

Rights of the Child (United Nations Convention on the Rights of the Child)

  1. The Ministry of Children and Youth Services amend the Child and Family Services Act to incorporate the United Nations Convention on the Rights of the Child (UNCRC), including in the purpose/interpretation sections, and in all areas where Article 12 of the UNCRC would apply.

Quality Improvement

  1. The Ministry of Children and Youth Services conduct a study to determine the impact of stigma and systemic stereotypes held by Children’s Aid Societies (CAS) and their workers with regard to indigenous clientele and the impact this may have on the effectiveness of service interventions they receive from both native and non-native CAS.
  2. The Ministry of Children and Youth Services review its accountability framework to ensure that it is exercising the required oversight of Children's Aid Societies (CAS) so that:
    1. CAS adhere to the Child Protection Standards and Tools in the delivery of child protection services, by routinely performing, without advance notice, random file reviews and comprehensive audits (child protection files, staff interviews,
    2. workers understand that the Child Protection Standards represent legislated minimums
    3. differences between CAS do not lead to inconsistencies in child protection services throughout the province
  3. The Ministry of Children and Youth Services consider implementing and funding a shared Intake Screening service in Toronto in order to simplify the process of contacting the appropriate Children’s Aid Society.
  4. The Ministry of Children and Youth Services require that all Children’s Aid Societies review with their staff recommendations from inquests and key findings and recommendations from the Office of the Chief Coroner’s Paediatric Death Review Committee (PDRC) relating to the deaths of children connected to the child welfare system. In particular, the Ministry circulate the recommendations from this Inquest touching the death of Katelynn Sampson to all Children's Aid Societies, to share the lessons learned from this tragedy.
  5. The Ministry of Children and Youth Services ensure that Children’s Aid Societies (CAS) of Ontario change their regular business hours from the current 9:00 a.m. to 5:00 p.m. to a 12-hour period such as 7:00 a.m. to 7:00 p.m., seven days per week. This will ensure greater availability of resources such as direct supervision, access to files and expertise. In addition, this will assist in having CAS provide service within 12 hours as prescribed in the Child Protection Standards.
  6. The Ministry of Children and Youth Services in consultation with Children’s Aid Societies (CAS) carry out an audit to determine what community resources are available, by region, that assist or support CAS services. The audit should also consider any waiting lists to access these community resources
  7. The Ministry of Children and Youth Services ensure that Children’s Aid Societies provide Emergency After Hours Services (EAHS) from a society office, rather than at home, and all supervisors, intake screeners/intake workers providing EAHS should work from a society office that allows them to access all resources including databases, files and staff support.
  8. The Ministry of Children and Youth Services provide for penalties to be imposed on any Children’s Aid Society and/ or child protection worker that omits, destroys or alters a child protection referral.
  9. The Ministry of Children and Youth Services fund and provide an infrastructure where all intake phone calls are to be voice-recorded in order to provide accuracy of information as well as for training purposes.
  10. The Ministry of Children and Youth Services collaborate with third party accreditors to implement a process by which Children’s Aid Societies (CAS) are accredited for quality (for example compliance with standards, staff training, protocols and client satisfaction) on a three-year basis. A CAS's accreditation standing should be made available to the public.
  11. The Ministry of Children and Youth Service establish:
    1. a consistent system to track Paediatric Death Review Committee recommendations and inquest recommendations that have been implemented or are in progress
    2. processes for generating regular reports such as the Ontario Child Mortality Task Force - Final Report (1997) and information relating to child deaths, for Ministry use, in order to support evidence-based decision-making
  12. The Ministry of Children and Youth Services ensure that Children's Aid Societies respond to all recommendations directed to them from child death reviews and inquests within a year. Responses should inlcude:
    1. an outline of actions taken
    2. a timeline for implementation
    3. a rationale for any recommendations not implemented
  13. The Ministry of Children and Youth Services consider the implications for blended families served by a child-focused child welfare system, and consideration be given to developing a standard to ensure that the child's identity and the child's views and preferences are important factors in determining service provision.

Information Sharing

  1. The Ministry of Children and Youth Services in consultation with Ontario Association of Children’s Aid Societies, Provincial Advocate for Children and Youth and Office of the Children’s Lawyer, provide a legislative framework for information sharing between Children’s Aid Societies (CAS), that includes disclosure from CAS to third parties, and other government agencies to CAS. Subsequently, protocols should be developed in order to ensure consistency amongst CAS and to third parties and other government agencies.
  2. The Ministry of Children and Youth Services direct Children’s Aid Societies of Ontario to no longer restrict files (masked or sealed) to child protection workers by requiring additional approvals, either internally or between agencies within the provincial context, to allow for unfettered access to complete information for child protection workers. Accountability should be emphasized regarding rules and policies on use and disclosure of personal information contained in child protection files.
  3. The Ministry of Children and Youth Services initiate the process of developing a province-wide protocol for the release of information and records from police services to Children's Aid Societies, and invite the participation of the Ontario Association of Children's Aid Societies, bargaining agents of the Societies, the Ministry of the Attorney General, the Ministry of Community Safety and Correctional Services, the Police Legal Advisors Committee of the Ontario Association of Chiefs of Police, the Royal Canadian Mounted Police and the Information and Privacy Commissioner of Ontario.
  4. The Ministry of Children and Youth Services modify the FastTrack Information System Policy on Security and Sharing of Information which governs FastTrack to be checked in non-parental custody applications and direct Children’s Aid Societies (CAS) to report child protection records in other CAS identified in FastTrack when responding to CAS record checks under the Children’s Law Reform Act.

Training

  1. The Ministry of Children and Youth Services establish and fund an authorization process for all child protection workers, supervisors and directors including:
    1. Defining of core competencies for various child welfare roles
    2. Determining the elements of the training curriculum required for authorization, and a testing or evaluation component to demonstrate that learning goals have been achieved
    3. Imposing clear restrictions and limitations on practice for unauthorised workers
    4. Setting continuing professional development requirements for maintaining authorization and a testing or evaluation component to demonstrate learning goals have been achieved
    5. Ensuring consideration of the child protection needs specific to Indigenous children, families and communities
    6. Emphasizing the importance of compliance with Child Protection Standards, Tools and Eligibility Spectrum
    7. There should be a provincial oath taken and certificate provided when a child protection worker receives their child protection authorization to reinforce the important role they play in child welfare and society at large

Only authorized child protection workers will have the authority to provide child welfare services that include, but are not limited to conducting investigations, apprehending children or making child protection applications to a child welfare court.

  1. The Ministry of Children and Youth Services work with Ontario Association of Children’s Aid Societies to develop a mandatory training curriculum on risk assessment. This curriculum should include areas related to: child risk assessment, analysis of historical information, administration of risk assessment tools, critical analysis, development of a service plan and the changing nature of risk assessment.
  2. The Ministry of Children and Youth Services direct the Ontario Association of Children’s Aid Societies to develop a standard training module to provide child protection workers with appropriate assessments and intervention techniques for use when working with children and adults who experience mental illness, substance use disorders or developmental delay. This module should also include special considerations for diverse cultural groups.
  3. The Ministry of Children and Youth Services introduce mandatory annual training regarding the provincial standards for child protection work under the Child and Family Services Act.
  4. The Ministry of Children and Youth Services conduct consultations on certification/authorization and on-going training requirements that go beyond the Ontario Association of Children’s Aid Societies, so as to include consultations with bargaining agents, the Provincial Advocate for Children and Youth and the Office of the Children’s Lawyer.
  5. The Ministry of Children and Youth Services in consultation with the Ontario Association of Children’s Aid Societies, Association of Native Child and Family Services Agencies of Ontario, Ontario College of Social Work and Ontario Provincial Advocate for Children and Youth consider increasing educational requirements for child protection workers to require them to have a Bachelor of Social Work and that additional education such as a Master's degree in a related field be considered an asset in the hiring process. Following this, Children’s Aid Societies will update their job descriptions accordingly.

Child Protection Information Network (CPIN)

  1. The Ministry of Children and Youth Services (MCYS) provide a mechanism, such as an online survey, for front-line workers using the Child Protection Information Network (CPIN) to provide anonymous feedback directly to the MCYS to ensure it receives accurate user-experience data. The MCYS should provide the results to the Children’s Aid Societies to be distributed to their front-line staff and indicate how issues will be addressed either through application amendments or additional training.
  2. The Ministry of Children and Youth Services ensure the final version of Child Protection Information Network (CPIN) incorporates all of the information and functionality of the Child Abuse Register (CAR). Once CPIN is fully implemented, the CAR should be retired.
  3. The Ministry of Children and Youth Services modify the Child Protection Information Network (CPIN) to include a flag that is specifically initiated/triggered for an individual who has been verified to have sexually or physically abused a child. This flag in CPIN should not be removable by a child protection worker.
  4. The Ministry of Children and Youth Services amend the Child Protection Information Network (CPIN) to ensure that the system records that children's views have been solicited (individually, privately and as appropriate for their age and maturity) at all critical junctures such as investigation, safety/risk assessment, development of service plan/plan of care, regularly-scheduled home/community visits, at times of files transition and at closing.
  5. The Ministry of Children and Youth Services provide dedicated resources for uploading legacy records into the Child Protection Information Network (CPIN) as PDF documents, so that they are accessible in full from the CPIN application.
  6. The Ministry of Children and Youth Services consult with and involve the organizations representing front line workers in any operational review or assessment of the Child Protection Information Network (CPIN).
  7. The Ministry of Children and Youth Services assess the utility of the current search function in the Child Protection Information Network (CPIN). Following this, MCYS will determine if the issue with the search function is a training issue or if a new search mechanism, similar to FastTrack, needs to be implemented.

Child Protection Standards

  1. The Ministry of Children and Youth Services review the Child Protection Standards to ensure that, where a person is entitled to access to a child, they are considered part of the assessment of risk and included in Children’s Aid Society service planning.
  2. The Ministry of Children and Youth Services (MCYS) undertake a workload study to examine the time required to conduct mandated services in accordance with the Child Protection Standards and use the results to inform the review of the funding formula currently underway. Subsequently, the MCYS should consider directing Children’s Aid Societies to submit routine workload analysis reports to assess whether agencies are properly resourced.
  3. The Ministry of Children and Youth Services amend the Child Protection Standards to include a provision that a child, at the start of a child protection investigation, be seen and assessed by a medical practitioner (physician/nurse practitioner). Confirmation from the practitioner should be sent to the child protection worker for inclusion in their file. Any expense incurred as a result should be borne by the respective agency.
  4. The Ministry of Children and Youth Services update Child Protection Standard (2016) #8 so that all child protection files at closing include a review of all available records and databases in order to ensure that the concerns identified at file opening have been addressed and that additional concerns have not arisen.
  5. The Ministry of Children and Youth Services revise the Child Protection Standards (2016) to provide conferencing and reconciliation in circumstances where there is disagreement among staff (including supervisors) regarding whether:
    1. a referral should be made to another society or another service provider
    2. there should be a change in coding
  6. The Ministry of Children and Youth Services commission an independent study to evaluate whether the use of the Eligibility Spectrum (2006) enhances or detracts from compliance with Child Protection Standards (2016) and if it hinders workers decision making.
  7. The Ministry of Children and Youth Services revise Child Protection Standard (2016) #1 to provide for:
    1. an immediate response where imminent harm is assessed by the intake screener;
    2. the intake screener who determines an immediate response is required and is responsible for contacting 911 or initiating the joint investigations protocol prior to passing the referral to another agency or worker.

As an interim step, we recommend all Societies in Ontario adopt this procedure.

  1. The Ministry of Children and Youth Services revise the Child Protection Standards (2016) to provide for the possibility of a less-than-12-hour response time, as specified by the child protection worker following the receipt of a referral, in consultation with his or her supervisor. The required response time shall be clearly specified in the intake/referral documents at the time the referral is coded under the Eligibility Spectrum. The supervisor shall then ensure and document that the referral is immediately assigned for investigation.
  2. The Ministry of Children and Youth Services amend the Child Protection Standards (2016) to require that supervisors complete case notes of supervision meetings.
  3. The Ministry of Children and Youth Services amend the Child Protection Standards (2016) to establish a requirement to record documents which have been reviewed by workers and supervisors at key points (referral, investigation, transfer to family service, supervision consultation, before file closed), and ensure that the Child Protection Information Network (CPIN) functionality tracks this requirement.
  4. The Ministry of Children and Youth Services review the Child Protection Standards (2016) to require that persons with access to a child be notified when a child is the subject in an ongoing child protection file subsequent to a child protection investigation.
  5. The Ministry of Children and Youth Services update and expand the use of the Ontario Child Protection Tools Manual (2007). In particular, update the contents of the Child Emotional Well-Being Screen (to make it more child-friendly) and lower the age for when the questionnaire may be used and provide direction that it is to be done directly with the child one-on-one and away from any caregiver or parent.
  6. The Ministry of Children and Youth Services review and update the Ontario Child Protection Required Tools (2007) sections 1 through 4 used for risk assessment, by applying current research, data and related standards. This should include tools to ensure that every caregiver with access be equally assessed and that there be an age-appropriate, child-friendly tool to establish children’s views. In addition, supplementary tools on alcohol use, substance abuse and mental health should be regularly updated to reflect current research and best practices.
  7. The Ministry of Children and Youth Services amend the Child Protection Standards (2016) to specifically provide that the Children’s Aid Societies (CAS) prepare a written synopsis of historical information of an individual’s involvement with CAS and their risk history. The verified written synopsis should travel with the file and be updated as needed. It must be emphasized this should not replace more detailed record checks as required.

Child Abuse Register (CAR)

  1. The Ministry of Children and Youth Services expand the circumstances in which the Child Abuse Register can be checked to include non-parental custody applications, by amending the Child and Family Services Act as well as updating the 1987 Interim Guidelines for Reporting to the Register.
  2. The Ministry of Children and Youth Services sanction or fine any Children’s Aid Society that fails to report verified abuse to the Child Abuse Register within the guidelines.

Funding

  1. The Ministry of Children and Youth Services consult with the organizations that represent front-line workers during the review of the Child and Family Services Act and the funding formula.
  2. The Ministry of Children and Youth Services (MCYS) immediately conduct a review of the services being provided by Children's Aid Societies (CAS), with a view towards determining whether the current funding model is limiting CAS’ ability to effectively carry out child protection services. In addition, MCYS establish a goal for communicating rolling multi-year funding to provide greater certainty and long range planning by agencies and the entire sector; and a pre-budget process take place whereby CAS submit their budget needs to MCYS and that those needs are given considerable weight when undertaking the annual budget process.

Multiservice vs. Single Service Model

  1. The Ministry of Children and Youth Services commission a third party to study the single service child protection model against the multiservice protection/prevention model in Ontario to determine if clients are better served through single or multiservice agencies. This study should examine:
    1. whether child protection services are diminished in multiservice agencies because of a lack of delineation between protection and prevention services (for example the family may be moved to prevention services when child safety concerns are still present).
    2. whether there are sufficient controls to ensure that funding for protection services is not re-allocated to prevention services

Ministry of Children and Youth Services (MCYS), Ministry of Education (ME)

Funding

  1. The Ministry of Children and Youth Services and the Ministry of Education provide funding to Children's Aid Societies and Boards of Education to enable the development and sustainment of collaborative projects between them. This should include funding for co-location projects, such as the pilot project initiated by Children’s Aid Society of Toronto with the Toronto District School Board at Parkdale Public School, as well as the development of protocols, mutual education and training.

Ministry of Children and Youth Services, Ontario Provincial Advocate for Children and Youth (PACY)

  1. The Ministry of Children and Youth Services in consultation with the Provincial Advocate for Children and Youth, develop a children’s rights pamphlet for children, in a variety of formats geared for different developmental ages, for use by Children's Aid Societies (CAS) to inform all children in families receiving services of their rights under the United Nations Convention on the Rights of the Child.

Ministry of Children and Youth Services, Ministry of the Attorney General (MAG), Family Rules Committee

Information Sharing

  1. The Ministry of the Children and Youth Services work together with the Ministry of the Attorney General and the Family Rules Committee to require the results from searches of FastTrack and successor province-wide Children’s Aid Societies (CAS) systems including the Child Protection Information Network (CPIN), as well as the Child Abuse Register (CAR), be placed before the court regarding CAS involvement in non-parental custody transfers. Searches should be done of all adult residents in the proposed new home, respondent(s) as well as the child who is the subject of the non-parental custody application. Any CAS receiving a request for child protection records from a provincial database should provide all records from the province listed, not just the records from that respective agency.

Ministry of Children and Youth Services, Ministry of Community and Social Services (MCSS), Offic of the Chief Coroner of Ontario (OCC)

Information Sharing

  1. The Ministry of Children and Youth Services, Ministry of Community and Social Services and the Office of the Chief Coroner of Ontario develop a protocol to ensure information is provided to parents and families (including a parent with access) following the death of their child to allow them early access to information about their child’s death, contributing factors and corrective actions the parties have put in place to prevent future deaths.

Ministry of Children and Youth Services, Ontario Association of Children’s Aid Societies(OACAS)

Training

  1. The Ministry of Child and Youth Services with Ontario Association of Children’s Aid Societies develop required training for all child welfare professionals (administrators, child protection workers, supervisors and prevention workers in multi-service agencies) regarding the rights of persons with access set out in section 20(5) of the Children's Law Reform Act (CLRA) that the entitlement to access to a child includes the right to visit with and be visited by the child and the same right as a parent to make inquiries and to be given information as to the health, education and welfare of the child.
  2. The Ministry of Children and Youth Services in collaboration with Ontario Association of Children’s Aid Societies develop mandatory training for all child protection workers on crisis intervention and how to establish and maintain therapeutic relationships, for example, boundary setting and communication skills.
  3. The Ministry of Children and Youth Services (MCYS) and the Ontario Association of Children’s Aid Societies (OACAS) clearly establish the components of standard initial and on-going training required for child protection workers and supervisors. Compulsory training must be established for different worker roles. The MCYS should determine a cycle of training for workers to ensure they receive updated compulsory training, which should include testing and formal individual evaluation. The MCYS should ensure effective oversight of the content and delivery of required training by the OACAS.

Ministry of Children and Youth Services, Ontario Association of Children’s Aid Societies, Association of Native Child and Family Services Agencies of Ontario (ANCFSAO), Children’s Aid Societies of Ontario

Quality Improvement

  1. The Ministry of Children and Youth Services and Children’s Aid Societies (CAS) of Ontario via Ontario Association of Children’s Aid Societies and Association of Native Child and Family Services Agencies of Ontario should establish reasonable caseload benchmarks for front-line workers and they should collect information on caseloads in a format that allows comparisons in order to determine whether current CAS caseloads are appropriate.
  2. The Ministry of Children and Youth Services and Children’s Aid Societies of Ontario via Ontario Association of Children’s Aid Societies and Association of Native Child and Family Services Agencies of Ontario develop and amend policies on drug assessment and testing, including the completion of unannounced home visits, where substance abuse is a potential concern.

Ministry of the Attorney General (MAG)

  1. The Ministry of the Attorney General amend section 24(4) of the Children's Law Reform Act to include neglect.

"Duty to Report"

  1. The Ministry of the Attorney General (MAG) train all court staff, upon hire and annually thereafter, on the "Duty to Report" suspected child abuse or neglect under the Child and Family Services Act. In addition, MAG should post information on "Duty to Report" in areas visible to court staff.
  2. The Ministry of the Attorney General consult with the judiciary or judicial training institutes respecting the "Duty to Report" suspected child abuse or neglect under the Child and Family Services Act by the judiciary, as well as training on the United Nations Convention on the Rights of the Child, and on how to elicit and give weight to the voice of the child.

Quality Improvement

  1. The Ministry of the Attorney General (MAG) work with its justice partners such as the Family Rules Committee to identify ways to standardize custody and access orders to assist self-represented litigants and promote the development of orders that clearly speak to the rights and responsibilities of persons with custody of, or access to, a child. MAG should also increase the availability of information about the rights of parents with access under the Children's Law Reform Act, section 20(5), for example, on their Ministry website.
  2. The Ministry of the Attorney General amend the Children’s Law Reform Act by incorporating a section similar to section 49 of the Child and Family Services Act, to provide that the court may, on its own initiative, summon a person to attend before it, testify and produce any document or thing, and may enforce obedience to the summons.
  3. The Ministry of the Attorney General amend the Children's Law Reform Act, Regulation 24/10 and Form 35.1 to require all adults residing in the home of the person seeking custody of the child, as well as the respondents and the child who is the subject, to provide criminal record checks, CAS and court file checks in a non­parental custody transfer.

Rights of the Child (United Nations Convention on the Rights of the Child)

  1. The Ministry of the Attorney General incorporate the United Nations Convention on the Rights of the Child into the purpose/interpretation sections of the Children's Law Reform Act.
  2. The Ministry of the Attorney General consult with the Office of the Children's Lawyer (OCL) and the Provincial Advocate for Children and Youth, with the goal of amending the Children's Law Reform Act, with respect to children who are the subject of a non-parent custody proceeding, in order to ensure their bests interests are met. The amendments should include the right of the child to:
    1. be informed at the beginning of the application process that they have a legal right to be heard
    2. express views and preferences freely, communicating and participating in a manner that works for them
    3. participate in any process affecting a change in their custody as an integral part of the determination of the child's best interest
    4. have their views considered in a substantive way and be informed of the result reached and the way in which their views have been take into account
  3. The Ministry of the Attorney General amend section 64 (1) of Children's Law Reform Act by removing "where possible" and adding: "The child has a right to express his or her views in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child."
  4. The Ministry of the Attorney General amend section 30(1) of the Children's Law Reform Act to ensure any appointed neutral assessor has an obligation to directly obtain from the child their views and preferences and the Ministry establish regulations to clarify the role of the assessor in non-parental custody proceedings.
  5. The Ministry of the Attorney General amend section 24(2) (b) of the Children's Law Reform Act so it reads: "The right of the child to express his or her views in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child."
  6. The Ministry of the Attorney General (MAG) amend the Children's Law Reform Act to ensure that independent evidence as to the views and preferences of the child in non-parent custody transfer proceedings be elicited and brought before the court. In consultation with stakeholders, including the Provincial Advocate for Children and Youth and the Office of the Children's Lawyer, MAG should consider a variety of ways to facilitate the child's right to participate pursuant to Article 12 of the United Nations Convention on the Rights of the Child.

Information Sharing

  1. The Ministry of the Attorney General revise the Children's Law Reform Act to provide that where a non-parent custody application has been filed, and the information received from a Children’s Aid Society (CAS) or court file search reveals there has been a recent CAS investigation or multiple openings involving the proposed caregiver or adults residing in the proposed household, that the court advise the CAS of a pending custody transfer proceeding, and that CAS may be asked to appear before the court to provide information relevant to the custody of a child.
  2. The Ministry of the Attorney General amend O. Reg. 24/10 of the Children's Law Reform Act (CLRA) regarding "Custody Claims by Non-Parents" to require:
    1. non-parents requesting a police records check use the prescribed form ("Consent Form for Police Record Check for Non-Parent Custody Applicants") to request this check as a means of ensuring that the police service is aware that the request is being made pursuant to section 21.1 of the CLRA and that all the records listed in the regulation must be produced
    2. the summary of the search results provided by the police explicitly identify that the check was made in response to a request pursuant to section 21.1 of the CLRA, a means of confirming that the check contains all of the records listed in the regulation.

Ministry of the Attorney general, Family Rules Committee

Rights of the Child (United Nations Convention on the Rights of the Child)

  1. The Ministry of the Attorney General and Family Rules Committee, where appropriate, amend forms and affidavits to provide for an option that includes ascertaining and recording the views and preferences of the child in a non-parental custody transfer.
  2. The Ministry of the Attorney General as well as the Family Rules Committee instruct the courts that a child must be heard by the court in all non-parental custody proceedings where appropriate (i.e. when age-appropriate and cognitively able).

Quality Improvement

  1. The Courts should be required to make best efforts to notify respondent parent(s), for example sending a registered letter to the last known address of the parent(s), when a non-parent applicant is seeking permanent custody of a child and the respondent parent(s) are not present in court.

Ministry of the Attorney General, Family Rules Committee, Office of the Children’s Lawyer

  1. The Ministry of the Attorney General work in collaboration with the Office of the Children’s Lawyer (OCL) and the Family Rules Committee to develop a protocol instructing the courts to send court documents, for all non-parental child custody transfers, to the OCL to determine their role, if any, in each case. This should be done in order to ensure the child’s rights are protected.

Ministry of Education

Rights of the Child (United Nations Convention on the Rights of the Child)

  1. The Ministry of Education incorporate the United Nations Convention on the Rights of the Child into the purpose/interpretation sections of the Education Act.

Quality Improvement

  1. The Ministry of Education circulate the recommendations from this Inquest touching the Death of Katelynn Sampson to all school boards, to share the lessons learned from this tragedy.
  2. The Ministry of Education develop a Policy/Program Memorandum on internal and third party external reviews to be conducted and initiated by school boards where a child enrolled in school in Ontario has died as a result of suspicious circumstances, indicating abuse or neglect, including homicide.
  3. The Ministry of Education consult with school boards, the College of Social Workers and the Consent and Capacity Review Board in Ontario to develop a policy or protocol with respect to the ability of school social workers to provide services directly to students who are capable to consent to service, without a requirement for parental consent.
  4. The Ministry of Education reassess the number of social workers to Toronto District School Board schools and their ability to deliver mandated services. The Ministry should then consider decreasing the ratio of students to social workers by allocating more social work resources and appropriate funding.

Information Sharing

  1. The Ministry of Education consult with school boards, the Provincial Advocate for Children and Youth, youth with lived experience in the child welfare system, the Information and Privacy Commissioner, the Ontario Association of Children’s Aid Societies and the Association of Native Child and Family Services Agencies of Ontario with respect to its policies regarding Children’s Aid Societies (CAS) and legal custody-related information being placed on the Ontario Student Record (OSR). The consultation should specifically consider the United Nations Convention on the Rights of the Child, Article 12 (the child's right to be heard) and Article 16 (the right to privacy).

The consultation should include the Education Act provisions and the Ontario Student Record Guidelines and:

  1. Address records and information that may be kept in the OSR, including documentation of reports to, and consultations with, CAS about suspected abuse and neglect, as well as legal custody documents or legal custody decisions
  2. Address if CAS-related information is not kept in the OSR, where the information should be retained
  3. Address who is entitled to access an OSR
  4. Ensure that the process for removing records from the OSR can be initiated by a student who is still a minor

Curriculum

  1. The Ministry of Education work in consultation with school boards to create new K-12 curriculum that addresses human rights and the United Nations Convention on the Rights of the Child in an age-appropriate way. The curriculum should include explicit references to the rights afforded to children under the UNCRC, including but not limited to: their right to be protected from violence, to have their views considered when decisions are made about them, to education (including the right to regular attendance at school) and to health care (including the right not to be deprived of health care services). Learning expectations should also include explicit references to abuse and neglect within a familial context and identify neglect as an example of an exploitative behaviour. The new curriculum should also be subject to regular testing and evaluations to determine if students are learning key information regarding rights, harm (including neglect), reporting, finding help, consent, boundaries and self-care.
  2. The Ministry of Education review the curriculum to establish a mandatory learning expectation that all students in Ontario receive instruction on their duty, as citizens, to report suspected child abuse and neglect under the Child and Family Services Act before the end of high school, and that the Ministry consider incorporating the "Duty to Report" in the civics course in high school. The Ministry of Education consult with Children's Aid Societies to develop resources to support teachers in providing appropriate instruction to students about the "Duty to Report".

Ministry of Community Safety and Correctional Services (MCSCS)

Information Sharing

  1. The Ministry of Community Safety and Correctional Services consider amendments to the Police Services Act, O. Reg. 265/98, Disclosure of Personal Information, that would explicitly authorize the disclosure of any personal information about an individual to a Children's Aid Society (CAS) when;
    1. a member of the police service is reporting a reasonable suspicion that a child may be in need of protection to the CAS pursuant to section 72 of the Child and Family Services Act; or
    2. a CAS is conducting an investigation into allegations that a child may be in need of protection

Ministry of Health and Long Term Care

"Duty to Report"

  1. The Ministry of Health and Long-Term Care ensure that Emergency Medical Service Providers, including paramedics, are provided with annual training on the "Duty to Report".

Ontario Association of Children’s Aid Societies

Training

  1. The Ontario Association of Children’s Aid Societies should provide training to child protection workers on critical thinking and how to appraise as well as document clinical summaries related to the level of risk to a child. Child protection workers must exercise clinical judgement when doing their work and not rely rigidly on rules and procedures.
  2. The Ontario Association of Children’s Aid Societies provide training on custody transfers in Ontario to ensure that all child protection workers have a strong understanding of custody issues. Training should emphasize that when child protection workers become aware of risks to a child posed by a formal or de facto change of custody, including non-parental custody transfer, the matter should become a child protection investigation. If there is a recent child protection opening with another society, the case should be referred to that Children’s Aid Society for investigation.
  3. The Ontario Association of Children’s Aid Societies develop specific training to assist child protection workers in managing cases with complex (non-parent, access parent, disputes) custody issues, that may impact upon service delivery, multi-agency involvement, collaborative case conferencing and risk assessment.
  4. The Ontario Association of Children’s Aid Societies review the adequacy and frequency of training for supervisors to ensure that training requirements are sufficiently robust particularly in the area of clinical supervision.
  5. The Ontario Association of Children’s Aid Societies address training issues surrounding sexual abuse with a focus on the assumptions that workers may have regarding sexual preference of verified sexual abusers when assessing the safety of a child.

Eligibility Spectrum

  1. The Ontario Association of Children’s Aid Societies re-examine the Eligibility Spectrum (2006) to ensure that the child is at the centre of a referral. Current coding solely rates caregivers and this re-examination must ensure changes are made so that coding more accurately reflects the child's situation and to provide for the possibility that a file may be opened in a child's name.
  2. The Ontario Association of Children’s Aid Societies review and update the Eligibility Spectrum (2006). The language in the Eligibility Spectrum should be revised to be consistent with the language in the Child Protection Standards (2016) (e.g. verified vs. convicted). The Eligibility Spectrum should be routinely reviewed to ensure it reflects the most current approaches in the child protection field.

Ontario Association of Children’s Aid Societies, Associations of Native Child and Family Services Agencies of Ontario, Children’s Aid Socieites of Ontario

Quality Improvement

  1. The Children's Aid Societies of Ontario via Ontario Association of Children’s Aid Societies and Association of Native Child and Family Services Agencies of Ontario develop a policy dictating that a clear audit trail (worker name/number, date/time stamp) be available where there are changes to records after entry.
  2. The Children's Aid Societies of Ontario via Ontario Association of Children’s Aid Societies and Association of Native Child and Family Services Agencies of Ontario revise the Interagency Protocol to ensure direct consultation between two agencies’ intake screeners and supervisors when an agency receiving a transferred referral changes an initial determination that an investigation must be done. A rationale for not doing an investigation should be documented in the case file.
  3. The Children's Aid Societies of Ontario, Ontario Association of Children’s Aid Societies and Association of Native Child and Family Services Agencies of Ontario develop a clear directive that no front-line worker is to carry out any mandated child protection service without appropriate training and supervision.
  4. The Children's Aid Societies of Ontario, Ontario Association of Children’s Aid Societies and Association of Native Child and Family Services Agencies of Ontario ensure the determination of a child’s family constellation is accurate and routinely reassessed. Child protection workers must take great care when using and documenting familial terms in child protection files (e.g. aunt, uncle, father and mother). If the relationship between a child and other individuals is unclear it should be stated. This is necessary to ensure risk factors are properly determined.

Ontario Association of Children’s Aid Societies, Association of Native Child and Family Services Agencies of Ontario

Training

  1. The Ontario Association of Children’s Aid Societies and Association of Native Child and Family Services Agencies of Ontario consider working with educational institutions (Council of Ontario Universities) to inform them of the competencies required by the child protection sector in order to ensure they are available to students in the Social Work department.

Children’s Aid Societies of Ontario

  1. The Children's Aid Societies of Ontario should work together in a spirit of cooperation and support of each other's efforts in recognition of the mandate to provide a unified child protection community, particularly in overlapping jurisdictions. Efforts could be made to encourage this through team building exercises such as joint conferences, staff exchange programs and other joint facilitative opportunities. A survey regarding perceived barriers between agencies could be done to identify areas where cooperation could be improved.

Quality Improvement

  1. The Children's Aid Societies (CAS) of Ontario when dealing with referrals involving blended families, ensure the child's identity, views and preferences are important factors guiding the choice of which CAS is to deliver services.
  2. The Children's Aid Societies (CAS) of Ontario adopt a policy that when a caregiver requests removal of a child, 12 years of age or under, from the home, the referral must be coded extremely severe with a mandatory 12-hour response time, during which the child must be seen.
  3. The Children's Aid Societies of Ontario require that any designated child protection worker, as defined by s.37 (1) of the Child and Family Services Act, in their employ with the requisite degree or diploma, be registered with the Ontario College of Social Work.
  4. The Children's Aid Societies of Ontario implement a partner system for initial child protection investigations to ensure individual interviewing of a child and of caregiver(s), to ensure worker safety, and to offer a second clinical point of view.
  5. The Children's Aid Societies of Ontario review policies relating to the abuse of children and youth to ensure those policies employ expansive language relating to child maltreatment so as to incorporate abuse, neglect, emotional harm and physical harm envisaged and articled in section 37 of the Child and Family Services Act.

Training

  1. The Children's Aid Societies of Ontario train their workers regarding the rights set in out in section 20(5) of the Children's Law Reform Act that the entitlement to access to a child includes: the right to visit with and be visited by the child and the same right as a parent to make inquiries and to be given information as to the health, education and welfare of the child.

Office of the Chief Coroner of Ontario, Children’s Aid Societies of Ontario

Quality Improvement

  1. The Office of the Chief Coroner as well as all Children’s Aid Societies ensure that when a child death occurs, all child protection workers that had any involvement with the child and/or family, be informed of their involvement and interviewed for any Agency commissioned or Coroner's reports. Such worker interviews should be included in the reporting.

Toronto Children’s Aid Societies

Quality Improvement

  1. The four Toronto Children's Aid Societies providing services to the children and families of Toronto, adopt a shared Intake Screening service, utilizing a single telephone number in order to prevent confusion resulting from different numbers, to minimize lost referrals, to increase accessibility and to provide for pooling of resources.
  2. The four Toronto Children's Aid Societies ensure that in addition to requiring full attendance, training courses include a component to assess worker retention and understanding of course material.

Toronto Children’s Aid Societies, Toronto Police Services

Quality Improvement

  1. The Toronto Police Services and the four Toronto Children's Aid Societies incorporate the "Addendum: Children's Aid Society and Police Protocols, Investigation of Suspicious Child Deaths" from the Ministry of Children and Youth Services and the Office of the Chief Coroner into the next revision of the Toronto Joint Protocol for Investigations of Child Abuse.

Information Sharing

  1. The Toronto Police Services (TPS) and the four Toronto Children's Aid Societies (CAS) develop a protocol to govern the release of information and records from the TPS to the CAS. This protocol should address the process by which requests for information and records are made, the types of records that will be produced and any conditions or terms for the release of these records.

Native Child and Family Services of Toronto (NCFST)

  1. Native Child and Family Services of Toronto understand that the onus in determining child protection needs rests on the agency. The agency should take initiative and engage actively in both the gathering and verification of information in child protection matters.

"Duty to Report"

  1. Native Child and Family Services of Toronto (NCFST) provide an improved process for prevention workers and supervisors to report concerns to protection services under the "Duty to Report". In addition, NCFST should provide appropriate ongoing "Duty to Report" training to prevention workers and supervisors.

Quality Improvement

  1. Native Child and Family Services of Toronto should review the recommendations from this Inquest touching the death of Katelynn Sampson with staff, to share the lessons learned from this tragedy.
  2. Native Child and Family Services of Toronto develop/update a protocol regarding the assessment and management of risk arising from allegations of sexual abuse, including the identification of professional resources for the assessment of such risk.
  3. Native Child and Family Services of Toronto review and update all outdated policies and manuals, for example, the 2004 manuals "Risk Assessment Model for Child Protection in Ontario", "Intake Services", "Telephone Intake", "Family Services" and "Emergency After Hours Service", to ensure that they are in line with the Child Protection Standards (2016) and reflect best practices and current research in the field. This process of updating policies and manuals should be done on an on-going basis.

Training

  1. Native Child and Family Services of Toronto provide additional training to its workers and supervisors in the development of family service planning and service delivery to ensure that:
    1. Service plan development, interventions, action and contact are purposeful and relevant to addressing critical issues and risk factors. The plan should be clear in case documentation.
    2. Information from key collaterals regarding the progress of a service plan should be proactively sought, verified and documented.
    3. Case conferencing should be utilized where appropriate to ensure all current workers are apprised of recent risk assessment outcomes and service delivery plans.
    4. Supervisors should review and evaluate service plans for effectiveness and compliance with the Child Protection Standards in consultation with workers.
  2. Native Child and Family Services of Toronto train its workers and supervisors on issues relating to accuracy and completeness of documentation, ensuring:
    1. Closing dispositions must relate to or address changes to opening disposition
    2. All documents must clearly indicate the name of author and/or source of information. Documents must be dated/time-stamped in a consistent manner
    3. Note-taking and documentation must be clear and comprehensive, including notes relating to parent/caregiver and child interviews
    4. Information in documents and reports which is cut and pasted from other reports must have the originating source clearly referenced with the date and name of the prior worker or report sourced
    5. All decisions should be documented along with their rationale. Any deviation from the Child Protection Standards (2016), internal protocols or identified service plan goals must have a clearly documented explanation with supervisor approval
    6. All documents reviewed by a worker or supervisor to inform decision making must be listed by name of report, author and agency, and date/time-stamped
    7. All files are checked to make certain that searches of all key available databases [i.e. the Provincial Database; the Society's internal database and the Child Abuse Registry (as applicable)] are completed upon referral in all cases. All individuals identified, including children, must be searched and maintained in the file
  3. Native Child and Family Services of Toronto train its child protection workers (including supervisors) on issues of service plan goal abandonment with respect to mitigating risk in a child protection case, highlighting the following:
    1. A fully documented rationale must record both supervisor consultation and approval of abandoned goals. New service plan goals are to be developed and recorded in the file indicating how the new plan provides a better mitigation of risk to the child.
    2. Where a change in circumstances results in goal abandonment, the source of verification is to be identified and recorded on the case file. Self-reports are not sufficient evidence to abandon goals.
    3. Workers must not close a file with abandoned or incomplete goals unless the minimum criteria have been met, as stated in the Child Protection Standards (2016) #8, which includes that the risk factors identified no longer exist and have been reduced as to no longer pose concerns to the direct safety or well-being of the child.
    4. When a file is closed with abandoned goals, the supervisor must apply and prove their process of clinical judgement and document that the minimum criteria could not be met, as stated in the Child Protection Standards (2016) #8.
  4. Native Child and Family Services of Toronto train its workers to ensure that upon internal case transfer between workers:
    1. The current case manager and/or supervisor must convene, attend and document case conferences when discharging or transferring a case
    2. The current case manager and/or supervisor provide an overview of critical issues regarding current involvement, risk factors past and present, overall progress and outcomes of goals established as part of service plan or risk assessment
    3. The current case manager and/or supervisor must convey all information that will assist new workers in developing relevant plans and the awareness of potential risks
    4. On receipt of a transferred file, workers must independently complete a thorough review of the files in order to verify whether there is missing and incomplete information. Following the review, if any discrepancies are found, they should be corrected and changes documented to ensure the next case manager will see where changes and updates have been made

Child Abuse Register

  1. Native Child and Family Services of Toronto report all instances of verified abuse to the Child Abuse Register in a timely manner in accordance with the Ministry of Children and Youth Services 1987 Interim Guidelines for Reporting to the Register

Children’s Aid Society of Toronto, Native Child and Family Services of Toronto

Quality Improvement

  1. The Children's Aid Society of Toronto and Native Child and Family Services of Toronto implement measures to routinely audit the type and frequency of supervision received by child protection workers during investigations to ensure the Supervision Standards are being followed.
  2. The Children's Aid Society of Toronto and Native Child and Family Services of Toronto ensure information from internal and external reviews, including Paediatric Death Review Committee reports and inquests, following the death of a child are shared with staff, so action may be taken promptly to address issues emerging from such reviews.
  3. The Children's Aid Society of Toronto and Native Child and Family Services of Toronto, in cases where an agency is suggesting a protection file be closed and the caregiver is asking for it to stay open, the agency should consider this a significant risk and engage both protection and prevention supports as well as initiate case conferencing prior to considering closure.

Training

  1. The Children's Aid Society of Toronto and Native Child and Family Services of Toronto train their workers with respect to the importance of seeking police records in order to inform risk assessments when they become aware of criminal activity that could impact the safety of a child or risk to a child. When seeking collateral information from the Toronto Police Services (TPS), the best practice is to obtain consents for the release of this information as this will yield the most comprehensive information about police contacts with the family. Those records must be clearly documented in the protection file. Workers must review the information in order to determine the relevance of risk to a child and document the decision to use or not use such information in risk assessments. Information from the TPS should be sought at regular intervals when the protection concerns pertain to risks such as alcohol/substance misuse and domestic violence.
  2. The Children's Aid Society of Toronto and Native Child and Family Services of Toronto train their workers to effectively utilize secondary coding from the Eligibility Spectrum when they become aware of additional concerns. All intake screeners should be trained to secondarily code when record searches, collateral inquiries or family history reveal new information which raises additional issues of risk.

Children’s Aid Society of Toronto

Quality Improvement

  1. The Children's Aid Society of Toronto review recommendations from this Inquest touching the death of Katelynn Sampson with staff, to share the lessons learned from this tragedy.

Child Abuse Register

  1. The Children's Aid Society of Toronto report all instances of verified abuse to the Child Abuse Register in a timely manner, in accordance with the Ministry of Children and Youth Services 1987 Interim Guidelines for Reporting to the Register.

Office of the Chief Coroner of Ontario

  1. The Office of the Chief Coroner (OCC) request that all organizations and institutions receiving these recommendations provide a report updating their responses within a year of receipt. The OCC make responses to this Inquest publicly available.

Toronto District School Board (TDSB)

"Duty to Report"

  1. The Toronto District School Board enhance the annual "Duty to Report" training of staff by expanding the component of the training that is devoted to group discussion and analysis of case scenarios, and potentially including representatives from a Children's Aid Society in this segment.
  2. The Toronto District School Board require all persons volunteering at the school during school hours shall be provided with written material about their "Duty to Report" suspected abuse and neglect.
  3. The Toronto District School Board enhance the annual "Duty to Report" training of staff by developing a case scenario based on Katelynn's circumstance to identify and discuss the possible indicators of abuse and neglect (i.e. absenteeism, questionable sites for bruises and behaviours or characteristics observed in adults who abuse children).
  4. The Toronto District School Board enhance the annual "Duty to Report" training of staff by including specific training or case scenarios related to managing the ongoing caregiver/student/teacher relationship following the making of a report to a Children’s Aid Society
  5. The Toronto District School Board should require that all casual and temporary staff who will be acting in the role of Principal or classroom teacher receive information on the "Duty to Report" prior to the beginning of their contract and receive training about the "Duty to Report" within six weeks of commencing their duties.

"Duty to Report" (Operational Procedures)

  1. The Toronto District School Board amend their Abuse and Neglect of Students Operational Procedure PR 560 (B.4 How to Report?) to include immediate notification of police whenever there is a perceived safety risk to a child due to delayed response by a CAS (for example: if the student may return home after school due to either an inability or delay in the CAS response).
  2. The Toronto District School Board revise Operational Procedure PR560: Dealing with the Abuse and Neglect of Students as follows:
    1. Paragraph 4, in section B.2: What to Report? be amended to clarify the meaning of "should not conduct an investigation” to prevent school employees from speaking with a caregiver or interviewing the child extensively, and the reasons for this
    2. Paragraph 6, in section B 4: How to Report? to read "If it is not apparent that an investigation has commenced within 24 hours, it is the responsibility of the Principal, supervisor or designate to contact the Children’s Aid Societies to ascertain the status of the investigation".
    3. Section B.4: How to Report? include a provision that if a child is absent from school anytime within five school days after a report has been made to the CAS, then the Principal should report this absence to the Children’s Aid Societies as a follow-up to the initial report
    4. Section B.4: How to Report? include a provision that an elementary student's homeroom teacher should be advised by the Principal in a timely manner of any calls made to CAS by other school staff
    5. Paragraph 7, in section B.3: When and To Whom to Report?, to add "a pattern of problematic attendance", when tied to any of the circumstances noted in (a) through (e) in the procedure, to prompt a call to the CAS
    6. Paragraph 7, in section B.3: When and To Whom to Report?, be amended to provide that the Principal should notify the appropriate CAS when the Principal becomes aware that a child known to have been reported to be at risk, found to be in need of protection or who was the subject of a report to the CAS during the same school year, has ceased attending the school, transferred to a new school, or is receiving home- schooling.
  3. The Toronto District School Board amend section B.6 of Operational Procedure PR560 to provide guidance to employees about what information can and should be conveyed to parents and guardians, including persons with entitlement to access to a child, following the making of a report to a Children’s Aid Society.
  4. The Toronto District School Board amend form 560 B to include consultations with Children’s Aid Societies' as well as a brief summary of the purpose for the report. Forms 560 A, B, and C should include the date and time of the incident and date/time/signature of the form completion.
  5. The Toronto District School Board operational procedure PR 560 "Dealing with Abuse and Neglect of Students" should be revised to remove any statement that teachers should not provide the name of the student subject when calling Children's Aid Society for a consult.
  6. The Toronto District School Board review the issue of how the school should track calls to a Society (including both calls to report abuse, and calls to consult), actions taken and direction provided by a Society, and steps taken to follow up on calls to a Society where there is no apparent action, as well as where records relating to the above should be collected.

Rights of the Child (United Nations Convention on the Rights of the Child)

  1. The Toronto District School Board incorporate the rights of the child under the United Nations Convention on the Rights of the Child, with development of and reference to learning resources/lesson plans geared toward the various grades and developmental levels of children.
  2. The Toronto District School Board provide professional learning for teachers by providing information/lesson plans/resources and strategies that will better support teachers' understanding and enhance professional capacity around the following, but not limited to, teaching children about the rights of the child under the United Nations Convention on the Rights of the Child (for example; empathy, student voice, boundaries, consent and recognising acts of violence, "reporting and asking for help").
  3. The Toronto District School Board (TDSB) ensure every TDSB student receives an agenda at the beginning of the school year that provides information in the common and/or school pages about the rights of the child under the United Nations Convention on the Rights of the Child. The common and/or school pages of the agenda should also have the numbers for the Kids HelpLine and the Student Safety Line. The Board should involve children and youth in the design of the common and school pages, and include where appropriate visual material and child-friendly language.

In addition to the student agenda, the Toronto District School Board disseminate information regarding the rights of the child under the United Nations Convention on the Rights of the Child throughout its schools in a variety of accessible and child­friendly formats.

Quality Improvement

  1. Toronto District School Board (TDSB) social workers, where there is a claim by a guardian or parent that a child is using the social services of a Children’s Aid Society, will verify the claim with that Society in order to gather information on the child in establishing whether TDSB social services are required.
  2. Toronto District School Board amend its policies, training and forms related to persons with access to ensure they reflect the rights set out in Section 20(5) of the Children’s Law Reform Act that the entitlement to access to a child includes the right to visit with and be visited by the child and the same right as a parent to make inquiries and to be given information as to the health, education (including attendance records) and welfare of the child.
  3. The Toronto District School Board ensure greater visibility of social workers in the schools through such measures as:
    1. Introducing social worker to students at beginning of the year assemblies, or by visiting individual classrooms to discuss services offered
    2. Including material in the agenda about the role of the social worker as well as their contact information
    3. Posting of times/days when the social worker is at the school
  4. The Toronto District School Board communicate to students of all ages, in appropriate child-friendly formats, the availability of support services provided by staff including social workers, guidance counsellors, and psycho-educational consultants.
  5. The Toronto District School Board revise the Form 560C Checklist for Reporting to a CAS to include the telephone numbers of all Toronto Children's Aid Societies.

Information Sharing

  1. The Toronto District School Board establish in its policies and procedures that the Principal act as a nexus of information between Children’s Aid Societies, teachers, administration staff, social workers and Toronto Police Services. Principals are to be engaged with and relied upon when issues of child safety arise.
  2. The Toronto District School Board work with the four Toronto Societies to develop better information-sharing practices between societies and schools to assist in identifying, reporting and monitoring concerns regarding abuse and neglect.
  3. The Toronto District School Board determine how and where notes/documentation about individual students made by Principals, Vice-Principals, teachers, and staff are stored and shared among staff, in order to ensure:
    1. all staff involved with a student are aware of any potential issues of abuse or neglect
    2. incoming or coverage staff will have an accurate and complete picture of these issues
    3. when a child transfers to a new school within the TDSB, staff at that school will be aware of any issues of concern
    4. information is maintained in a secure location and access is restricted to designated staff in order to protect the student's privacy

Training

  1. The Toronto District School Board continue the annual training for administrators about their duty to follow up with the Children’s Aid Societies if no apparent action is taken in response to a report to a Society, and the steps they may take in this regard, and should incorporate a case scenario based on Katelynn's circumstances to illustrate the importance of follow-up.
  2. The Toronto District School Board conduct annual face-to-face training on abuse and neglect which should be completed within the first six weeks of the school year. In the event of job action, written materials should be distributed to all staff with direct contact with students within the first two weeks of the school year, and in-person training conducted within 12 weeks of the conclusion of the work stoppage.

Attendance

  1. The Toronto District School Board revise Operational Procedure PR707A, Student Attendance and Safe Arrival Procedures [Elementary], section C.2, to add a request for a home visit by an attendance counsellor (social worker) or call to Children’s Aid Societies to ensure that a child is seen, as one of the key options in dealing with problematic attendance issues. This section of the policy should also indicate that absenteeism on its own may be reportable, given the circumstances, as an indicator of neglect or abuse.
  2. The Toronto District School Board continue its efforts to implement an electronic system of attendance flag alerts (at the 5, 10, and 15 day points) in, or alongside, the Trillium program. Flag alerts should also capture missed half-days.
  3. The Toronto District School Board Revise Operational Procedure PR707A, Student Attendance and Safe Arrivals Procedures [Elementary], section C, section C.2, subparagraph (e) to require that Principals in all cases request external confirmation (which might include a medical note, travel verification, or that the child be seen by a school official) to verify absences (actual or projected) that exceed 10 consecutive days or 10 out of 30 cumulative days. Section C.2 should also be amended to reflect the accumulation of half day absences in identifying an implementation plan.

Toronto Police Services (TPS)

"Duty to Report"

  1. The Toronto Police Services develop a strategy to broadly distribute the pamphlet developed by the Ministry of Children and Youth Services on the public's "Duty to Report" child abuse and neglect, including training its members to provide this pamphlet to the person(s) who is interviewed as part of a child abuse or child homicide investigation.
  2. The Toronto Police Services ensure all police officers are provided with ongoing, mandatory training at regular intervals on their "Duty to Report" and the recognition of the signs of child abuse and neglect, and should collaborate with the Toronto Children's Aid Societies in developing and delivering this training. There should be an emphasis on personal responsibility to report and the potential "Duty to Report" in domestic occurrences.

Quality Improvement

  1. The Toronto Police Services consider identifying a single contact person or department within the Service who will respond to telephone inquiries from Children's Aid Society workers who are seeking personal information about individuals, as a means of ensuring that the member responding to the call has the training and experience to respond effectively and the information is provided in a consistent manner.
  2. The Toronto Police Services, in cases involving possible domestic conflict when children are present in the home, should observe the children for signs of abuse and neglect and include a description of the children in the police report.

Information Sharing

  1. The Toronto Police Services (TPS) take into account the potential importance of police record and occurrence report information to risk assessment and child protection. Upon the development of a protocol with the four Toronto Children's Aid Societies (CAS), the TPS should amend the Service Procedure on the disclosure of personal information pursuant to O. Reg. 265/98 of the Police Services Act to provide guidelines on the personal information that may be shared with a CAS when:
    1. a member of the police service is reporting a reasonable suspicion that a child may be in need of protection to the Children's Aid Society pursuant to section 72 of the Child and Family Services Act
    2. a CAS is conducting an investigation into allegations that a child may be in need of protection
    3. a CAS is seeking information about an individual in the course of providing ongoing service to a child and family, and the information would assist with risk assessment and protection of the child.

Toronto Police Services, Toronto Emergeny Medical Services (EMS)

"Duty to Report"

  1. The Toronto Police Services and Toronto Emergency Medical Services amend their policies and procedures to include that when a child under 16 years of age dies under suspicious circumstances, the relevant Children’s Aid Society must be informed in circumstances where other children may also be at potential risk of harm.

Legal Aid Ontario

  1. Legal Aid Ontario instruct their staff/counsel that when filling out forms relating to non-parent custody transfers, the information, if not verified, is clearly stated as not substantiated and represents the opinion of the applicant only.

National Judicial Institute

  1. The National Judicial Institute provide training to the judiciary with respect to their "Duty to Report" as well as training on the United Nations Convention on the Rights of the Child and on how to elicit and give weight to the voice of the child.

One Agency

  1. Urge the Ministry of Child and Youth Services (MCYS), notwithstanding our previous recommendations, to strongly consider the incorporation of child protection services in Ontario under one provincial structure in consultation/partnership with Association of Native Child and Family Services Agencies of Ontario, Ontario Association of Children’s Aid Societies as well as representatives from other cultural and religious agencies with a child protection mandate in order to:
  • minimize jurisdictional barriers within and between communities and the variety of joint protocols including case conferences currently required for case transfer
  • remove barriers to information sharing, such as ownership of information
  • remove confusion over agency jurisdiction of children in blended families
  • take advantage of economies of scale including the sharing of services such as finance and administration
  • create the opportunity for worker mobility where specific competencies may be in demand
  • ensure indigenous-specific competencies are available province wide
  • ensure competencies province-wide regarding special needs, i.e. substance and alcohol abuse and parents/children with disabilities
  • facilitate access to workers with diverse cultural competencies
  • reduce duplication of efforts in the child protection system
  • facilitate the adoption of best practices and ensure consistent application province-wide
  • create one province-wide number for which to stream all referrals and consultations
  • minimize the differences in organizational culture and nomenclature that currently exists between different agencies
  • allow for quicker and more efficient widespread adoption of new technologies
  • ensure that MCYS assume full responsibility for the delivery of child protection services

As the Child Protection Information Network (CPIN) is implemented across all Children's Aid Societies in the province, this may facilitate an opportunity for each agency to come under one provincial structure.