Baby Malachi is far from the only children's aid society client to have died in the province.
The four-month-old prematurely born baby boy was brought to Health Sciences North July 4, where he was pronounced dead.
He had been under the care of foster parents assigned by the Children's Aid Society of the Districts of Sudbury and Manitoulin for just two days before his death.
Malachi's death is now under investigation by the coroner's office, Greater Sudbury Police and the children's aid society.
CAS clients who die are, fortunately, relatively rare, but it does happen.
In 2010, the last year for which statistics are currently available, 107 such deaths were reported to the committee, Dr. Dirk Huyer, chair of the province's Pediatric Death Review Committee, said.
Huyer said 100 is about the average number of deaths that occur among CAS clients every year.
According to a five-year average, about 26,000 children are served per year in some way by a children's aid society, according to information provided by the Ontario Association of Children's Aid Societies.
The deaths included in the 2010 report represent about 0.3 per cent of the average number of people served yearly by children's aid societies.
More than half of these children were in a medically fragile state, Huyer said.
It is important to note that it is even more rare for children in foster care to die. The figures in the report include all of those who have had contact with CAS in the prior year.
Twenty-two of them were, like Malachi, being cared for by guardians appointed by a children's aid society.
Working under the Office of the Chief Coroner, the Pediatric Death Review Committee's members include coroners, medical and child welfare experts, police, pathologists, a child maltreatment expert and a Crown attorney.
The committee examines the reasons behind child deaths in the province in their yearly report, including children with children's aid society involvement, and makes recommendations for how these deaths could have been prevented.
The latest report, released in June 2011, examines work done by the committee in 2010.
Most of the child deaths analyzed by the committee in 2010 actually occurred in 2009 and before, although the report does provide a high-level overview of 2010 deaths.
The analysis offered in the report doesn't include all children who die while under children's aid society care, either, he said.
The committee is more likely to delve into cases where the cause of death isn't as clear-cut and might be preventable, he said.
The latest report provides a detailed analysis of the deaths of 49 children who had some involvement with a children's aid society in the last year of their lives.
Six of these children were under the care of a children's aid society when they died, and the rest had some other type of involvement with the agency.
Accidental deaths, at 37 per cent of the total or 18 children, represent the highest number of deaths in the report, with the vast majority dying in fires.
Those deaths classified as an “undetermined” cause represent 35 per cent of the total, or 17 people. Of those, 15 had sleeping arrangements with the review panel characterized as “unsafe.”
Natural deaths and homicides account for 10 per cent each, while suicide, at eight per cent of the total, was the least common cause.
Many of the children whose deaths were analyzed in the report are very young.
Forty-three per cent of them were under the age of one, 31 per cent were ages one to five, 10 per cent were between the ages of five and 14 and 16 per cent were over the age of 15.
Huyer said the committee is more likely to review deaths of children under the age of five because they often fall in the undetermined category.
“Many of the times with the young kids, the autopsies don't answer the question, so we get an autopsy that's negative,” he said. “It doesn't tell us why they die. We're going to do more analysis of these kids.”
As the statistics show, autopsies of these type of “undetermined” deaths, often associated with unsafe sleeping environments, Huyer said, don't usually give a clear-cut cause of death.
“If you're sleeping on a couch with your young baby, it's very risky,” Huyer said.
“You can turn over and the baby can get caught between you and the couch. A crib with three teddy bears in the corner is more safe but still defined as risky.”
While the Pediatric Death Review Committee's aim is not to assign blame, it does review cases with a view to preventing deaths in the future.
The report authors make a number of recommendations based on their findings, which have included encouraging safer sleep environments and greater compliance with installation and maintenance of working smoke alarms.
They have also called for enhanced information sharing among service providers and broader understanding of the impact of chronic neglect on children.
The director of communications with the Ontario Association of Children's Aid Societies, the organization representing the province's children's aid societies, said it's never acceptable when any children's aid society client dies.
“There are certain things that are preventable,” Caroline Newton said.
“(But) there are certain things where there are unfortunate natural causes, such as preexisting conditions and medically fragile children. Then there are things nobody can predict that take place.”
Whenever there is a death, children's aid societies work closely with the coroner as the case is being examined, and then implement their recommendations, Newton said.
Children's aid societies try their best to keep their clients safe, but said this task is also the responsibility of all of society, she said.
“It's the responsibility of parents, caregivers, neighbours and community partners,” Newton said. “The more people who feel that sense of responsibility, the more kids will be safe.”
To read the 2011 report of the Pediatric Death Review Committee, visit www.mcscs.jus.gov.on.ca.
Posted by Arron Pickard