Reviews and investigations of deaths of children receiving services - Alberta Human Services - Government of Alberta

Reviews and investigations of deaths of children receiving services

When a child receiving services dies, Children’s Services examines the incident to assess what happened and how the system can be improved. Learn more about our Internal Child Death and Serious Incident Review Process.

Deaths of children who were receiving services are also examined by a number of external and internal bodies, including:

The Office of the Chief Medical Examiner

  • The Office of the Chief Medical Examiner must be notified whenever there is a death of a child who was in care.
  • The Office of the Chief Medical Examiner conducts an investigation whenever a child’s death occurs suddenly or cannot be explained, or when the child is in the care or custody of Children's Services.
  • The investigation is held to determine general circumstances around the child’s death.
  • Over the last 10 years, causes of death for children in care as determined by the Chief Medical Examiner are:
    • medical (includes congenital anomalies, health conditions and disease) – 49%
    • accidental – 16%
    • undetermined (may include Sudden Infant Death Syndrome) – 13%
    • suicide – 10%
    • homicide – 10%
    • pending – 2%

Fatality Review Board

All deaths of children in care must also be reviewed by the Fatality Review Board for consideration for a public fatality inquiry unless the board is satisfied that the death was due to natural causes.

  • The Fatality Review Board may recommend a public fatality inquiry if there is a possibility of preventing similar deaths in the future or if there is a need for public protection or clarification of circumstances surrounding a case.
  • The Minister of Justice and Solicitor General calls the fatality inquiry, which is a public process overseen by a judge. The inquiry establishes cause, manner, time, place and circumstances of death, as well as the identity of the deceased.
  • Judges may make recommendations to prevent similar occurrences, but are prohibited from making findings of legal responsibility.
  • The Fatality Inquiries Act requires that a written report is made available to the public. The ministry provides a written public response to each report.

Child and Youth Advocate (CYA)

  • The Statutory Director notifies the Child and Youth Advocate whenever there is a serious injury or death involving a child receiving services.
  • The CYA may conduct their own investigation if they believe it will be in the best interest of the public.
  • A report must be provided to the Legislature. The ministry provides a written public response to each report.

Council for Quality Assurance (CQA)

  • The Statutory Director notifies the CQA of all serious injuries and deaths of children who were receiving services.
  • The CQA may recommend that the Minister appoint a panel of experts to review the circumstances surrounding the incident to assist in identifying potential improvements to the system.

Internal Examination by Ministry staff

Whenever there is an injury or death of a child receiving services, an internal examination of the circumstances is conducted to determine if improvements can be made to the child intervention system.

  • This could include examining files and talking to staff about the services and supports provided to the child.
  • Based on the findings of this process, decisions are made to determine if any immediate changes need to be made in policy or practice that could help prevent a similar incident.
  • In addition, case specific actions may be taken to support the immediate safety and well-being of the child or other children.

The ministry is committed to sharing learnings with staff throughout the organization and ensuring that staff are provided with opportunities to learn from real situations.

Modified: 2017-04-24
PID: 17189