Each inquest provides us with an opportunity to learn from the experience of one child or youth. What we do with and how we consider each recommendation from an inquest gives an indication of how we honour the lives of those children who have died.

Thomas King, award-winning novelist, scholar and author of, The Truth About Stories: A Native Narrative, a collection of stories about North America's relationship with its First Nations peoples, ends each of his stories with the following reminder to readers that storytelling carries with it social and moral responsibilities. "Take this story. It's yours. Do with it what you will. Tell it to friends. Turn it into a television movie. Forget it. But don't say in the years to come that you would have lived your life differently if only you had heard this story. You have heard it now."

In this spirit, we dedicate the inquest database to the children and young people connected to the child welfare, youth justice and mental health systems, many of whom live lives of incredible courage and resiliency all with great potential, yet who often are hidden in plain sight. We hear your stories.


In launching a public inquest database, the Office of the Provincial Advocate for Children and Youth hopes to promote, through increased public scrutiny, greater safety for children and youth in government care and an increased accountability of public institutions.

In Ontario, there were 26 inquests into the deaths of young people, who were connected to the care systems, including child welfare, youth justice and children's mental health, from 1995 to 2012. They were children and youth to whom the state had already expressed a public obligation to intervene on behalf of their best interest.


In 2007, the Office of the Provincial Advocate for Children and Youth (Advocate's Office) became an independent Office of the Legislature established under the Provincial Advocate for Children and Youth Act (Act). The mandate of the Office of the Provincial Advocate for Children and Youth is to provide advocacy in partnership with children and youth who are in, or on the margins of, government care. Subsection 2 (3) 1 of the Act requires the Advocate's Office to be an exemplar of meaningful participation of children and youth in all aspects of its advocacy services. As such, the Advocate's Office strives to conduct its work in such a manner that engages young people in meaningful and sustainable ways and supports young people to become agents of change. The Advocate's Office also adheres to, and promotes, the principles expressed in the United Nations Convention on the Rights of the Child (UN-CRC). In particular, Article 12 of the UN-CRC requires that the views of young people are given proper consideration and that young people have the opportunity to influence decisions affecting them.

In 2008, the Provincial Advocate for Children and Youth expressed his deep concern that the number of children and youth in care who died in Ontario is too high by any standard and raised the following challenge to Ontarians:
"It is important to acknowledge and thus honour the deaths of those children and youth by significantly fine-tuning our responses to their needs. They were, because of the state's obligation to their well being, "our children." It is also important to learn about the lives of the deceased in order to better serve the thousands of other children and youth in care, in children's mental health settings, and in custody, to whom we, as a Province, have made a commitment." Office of the Provincial Advocate for Children and Youth - Annual Report, 2007-2008

Coroner's inquests represent a key advocacy tool in promoting youth defined and directed change in the care systems. Specifically, inquests offer a forum for young people to play a key role in identifying the failings in the care systems and in generating and advocating for strategies for change. The inquest process also provides an important opportunity for the Advocate's Office to work alongside young people and to elevate the voice of young people in care. This includes young people in detention or custody, young people who are subject to restraints, young people with disabilities, racialized young people and First Nations young people. The Advocate's Office continues to be committed to involving and consulting with children and youth by actively including them in the inquest process.

The recommendations provided by Coroner's inquests are a critical safeguard for children and youth who are in the care systems. Throughout these inquests, juries have been productive in listing recommendations in an effort to prevent similar deaths in the future. This public inquest database is intended to assist with the tracking of Coroner's inquest recommendations and the responses of the recipient organizations.

In 2008, the Provincial Advocate made a commitment to follow the recommendations of Coroner's inquests into the deaths of children and youth connected to the child welfare, youth justice and mental health systems in order to determine general directions and to determine the number of recommendations that are subsequently implemented. To this end, in the 2008-2009 Annual Report, the Provincial Advocate announced that the Office of the Provincial Advocate for Children and Youth "will create an 'inquest database' so that young people and stakeholders will have access to recommendations from all inquests. This access will provide an opportunity for the public to bring increased pressure on government to act on the recommendations for change and potentially diminish the risk of more young people dying under similar circumstances".

In March of 2008, the Advocate's Office requested copies of the records including the verdict, recommendations and responses of the recipients [of inquests conducted regarding the deaths of children and youth connected in some way with Ontario's system of care since 1995] by submitting a written request to the Coroner's Office. Since 2008 the Advocate's Office has received the documentation for 26 inquests from the Coroner's Office. The recommendations and responses contained in this documentation have been posted on this public database. Many of the inquests raise similar issues and point to an apparent failure of the child welfare, youth justice and mental health systems to learn and apply important lessons from these tragic deaths.

Please note that portions of the inquest verdicts posted in this database have been redacted (a fancy way of saying that some information has been taken out or withheld). This step was taken to comply with various laws governing privacy and the information contained in the verdict including the Provincial Advocate for Children and Youth Act, 2007 and the Youth Criminal Justice Act. The Provincial Advocate values transparency and openness and is extremely conscious of the important right to privacy of the children and youth it serves. In some cases, the laws governing the Advocate's ability to disseminate information are more restrictive than privacy laws applicable to the government including the Office of the Chief Coroner which maintains copies of the verdicts maintained herein, sometimes with fewer redactions. The Advocate's Office is in the process of working towards changes in our Act that would allow us to provide more information on this data base and will make the appropriate changes when our Act is amended.

Members of the public with concerns regarding an inquest can contact the Coroner's Office directly and request [in writing] a copy of the inquest record in its entirety.

Links to the Coroner's Office and to the Advocate's Office Position Paper about inquests and Young People in Care can be found on the Resource Page of this database.

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