Devon Freeman Inquest

Background Information

Devon was an Indigenous youth from Georgina Island First Nation who was receiving services from Hamilton Children’s Aid Society when he died by suicide. Devon first went missing in October 2017 and his body was found in April 2018 on the property of the youth mental health facility where he was residing.

Devon Freeman’s death was a heartbreaking loss that was felt by all those who knew him and continues to have impact on his family, community and Nation. At the inquest into Devon’s death, the jury heard testimony from dozens of social service professionals, Indigenous advocates, family and community members. At the conclusion of the inquest, the jury made 75 recommendations.

Our Commitment

While these recommendations are directed at the service providers directly involved in the care of Devon, Dnaagdawenmag Binnoojiiyag will implement these recommendations. And furthermore, we will ensure that all service providers working alongside our children, youth, families, communities and Nations also adopt these recommendations.

Jury Recommendations

TO THE INSTITUTIONAL PARTIES (CHIPPEWAS OF GEORGINA ISLAND FIRST NATION, THE CHILDREN’S AID SOCIETY OF HAMILTON (“the Society”), LYNWOOD CHARLTON CENTRE (“LYNWOOD”) AND HAMILTON POLICE SERVICES (“HPS”) AND THE MINISTRY OF CHILDREN, COMMUNITY AND SOCIAL SERVICES (“MCCSS”):

1. Led by the Chippewas of Georgina Island First Nation, support the development and delivery of a case study training module for children’s aid societies and residential service providers regarding the lessons arising from Devon Freeman’s life and death and incorporate information from the Narrative document (with the exclusion of personal identifiers or information that may identify individuals or otherwise assign blame). Any requests to obtain and use video or other recordings from the inquest shall be made to the Office of the Chief Coroner for their consideration.

2. Use or continue to utilize neutral, descriptive language to describe young people who leave their place of residence without permission.

TO THE MINISTRY OF CHILDREN, COMMUNITY AND SOCIAL SERVICES:

3. Continue to work with bands and First Nation communities, including First Nations and urban Indigenous service providers, and Indigenous child well-being agencies to develop regulations as soon as possible that would support implementation and proclamation of amendments to the Child, Youth and Family Services Act, 2017 (the “CYFSA”) that received Royal Assent on March 3, 2022 through the Fewer Fees, Better Services Act, 2022 – Bill 84. This includes amendments that would provide a framework to distinguish customary care from residential care in specified circumstances and would not be subject to licensing requirements under Part IX of the CYFSA.

4. In accordance with subsection 1(2), paragraph 6, of the CYFSA, MCCSS should consider the need for a directive to children’s aid societies and licensed residential facilities to notify a child or youth’s bands and First Nation communities when a child or youth is absent from their residence without permission for more than 24 hours (and upon their return), is seriously injured, or dies in care and/or at the licensed facility.

5. Strongly recommend as part of the five-year review of the CYFSA that is currently underway, MCCSS is encouraged to engage with bands and First Nation communities and affiliated Indigenous stakeholders, and consider amendments that would require:

a. mandatory notification to a child or youth’s band or First Nation community when a child or youth is absent from their residence without permission for more than 24 hours (and upon their return);

b. mandatory notification to a child or youth’s band or First Nation community when a child who is a resident in a children’s residence dies, and in the event of any other serious occurrence, as listed at subsection 84(1) of the CYFSA;

6. To improve outcomes for First Nations children and youth, continue to work, through the Child Welfare Redesign Strategy, on potential further changes to the funding allocation and the child welfare service delivery model, including consideration of the following:

a. continue monitoring the effectiveness of annualized funding announced in July 2020 as part of the Child Welfare Redesign Strategy to provide access to prevention-focused customary care for bands and First Nation communities;

b. support the implementation of models of service to enable children and youth to have meaningful, lifelong connections to their family, community and culture; a sense of belonging; a sense of identity and well-being and physical, cultural and emotional safety; and that plans of care are reflective of the child’s physical, mental, emotional, spiritual and cultural identities beginning from the time a case is opened by a society;

c. continue to review the Ontario Eligibility Spectrum, the need for verification, and adopt a needs-based approach (instead of a caregiver deficits approach) to supporting and protecting the well-being of children and youth informed by Indigenous experts; and,

d. consider the need for Navigators, in addition to resource persons, adult ally and circle of supportive persons to assist First Nations youth, as both a prevention and protection resource and for youth both on and off reserve, in navigating various systems such as child welfare and protection, mental health and criminal justice.

7. To ensure that First Nations children benefit from their legal entitlements under An Act respecting First Nations, Inuit and Métis children, youth and families, engage with its federal counterparts to discuss support to children’s aid societies to meet the enhanced requirements regarding prevention, service provision, and reassessment.

TO THE MINISTRY OF CHILDREN, COMMUNITY AND SOCIAL SERVICES AND THE MINISTRY OF HEALTH:

8. In the spirit of recommendations made in the past in other settings, including those in the Safe with Intervention report, and in recognition of the ongoing need for more residential children’s mental health placements; the need for programs that address complex needs of children; the need for land-based programs and programs that prioritize connections with family, culture and community, we strongly recommend that the ministries work with Indigenous providers and communities to ensure that Ontario’s Indigenous Healing and Wellness Strategy includes:

a. residential treatment resources for Indigenous communities;

b. service coordination for children with complex trauma and complex needs to ensure safety, continuity of care, and the avoidance of long wait lists; and,

c. support for the development of programs that are flexible and able to respond to a range of needs including chronic and acute needs in a range of health and well-being domains.

9. In partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, establish multisectoral, multidisciplinary roundtables at local, regional, and provincial levels accessible to community members and service providers to problem-solve regarding service to young people with complex needs. These roundtables should include representatives of relevant government ministries, including Children, Community and Social Services, Health, Education, and Indigenous Affairs, community-based service providers, societies, Indigenous child well-being agencies, mental health lead agencies, children’s rights experts, educators, youth justice workers, and police as necessary.

TO THE HAMILTON POLICE SERVICES:

10. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a “pilot” project.

11. Work towards creating (including if necessary by making a request to the HPS Board for resources or funding) a new Missing Persons Unit (“MPU”) with the responsibility of coordinating and directing missing persons investigations. Any MPU that is created may still rely on officers from patrol or other divisions as appropriate in conducting missing persons investigations.

12. In developing an MPU, the HPS should consider and review the recommendations in Missing and Missed: The Report of the Independent Civilian Review into Missing Person Investigations and their application to the HPS. Specifically, they should consider:

a. Developing a strategic plan; including review and potential amendments to missing persons investigations (“MPI”) policies;

b. Giving priority to MPIs and change in culture;

c. Consistent coordination of MPI;

d. Use of civilian support workers, civilians in duties not required for a sworn officer related to MPI, coordination and family support;

e. Use of FOCUS tables;

f. Continuity of investigations;

g. Maintenance and development of community partnerships and, in particular, the Indigenous community;

h. Timely media releases;

i. Partnerships with youth institutions and, in particular, child and youth mental health facilities; and,

j. Creation of an implementation strategy.

13. Provide training for officers in the MPU, and other officers who may work in conjunction with the MPU, on missing persons investigations. Such training may include programs or courses offered by other police forces and/or programming put on by HPS officers with particular experience and expertise in missing persons investigations. Such training should address issues such as identifying and dispelling stereotypes that arise in relation to missing persons, conducting risk assessments for missing persons, collecting information from the person/organization reporting a missing person, using investigative tools and techniques that assist in conducting missing person investigations.

14. Review and revise the risk assessment process and policies that govern whether a missing person is classified as “Level 1” or “Level 2”, as well as whether an urgent search is required. The revised risk assessment factors, as well as search urgency factors, should be evidenced-based and clearly defined. In determining whether an MPI is classified as a “Level 1”, the revised process should require gathering additional information about the missing person, including but not limited to:

a. any history of suicidal behaviours (ideations or attempts);

b. whether the person is in an out-of-home placement at a mental health facility for children and youth; and,

c. whether the missing person is an Indigenous youth.

15. Once a risk assessment has been completed, ensure that all missing person cases are triaged to determine the appropriate response to a person’s disappearance, including whether that response should involve a combination of the police and/or other community organizations and/or a multi-disciplinary response. Consider an appropriate role for community members or organizations as part of the missing person investigation, or in a debrief with the missing person once the investigation is concluded.

16. Improve the HPS’ system for collecting and reviewing information relating to missing persons investigations, including considering the use of Powercase, alternatives to the Occurrence Enquiry Log system, and the ability to flag individual reports/occurrences where an individual demonstrates suicidal behaviours (ideations or attempts) (rather than just flagging the name of the individual).

17. In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. The protocol should address:

a. the circumstances in which a missing persons report should be filed;

b. the information to be provided as part of that report;

c. the residential home’s responsibilities prior, during, and after filing a report (including conducting a property search where appropriate);

d. the HPS’s responsibilities prior, during and after filing a report; and,

e. Responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth.

18. In consultation with organizations like Hamilton Children’s Aid Society and other agencies servicing high-risk youth, develop a joint process whereby HPS and other community stakeholders come together to review any case of a missing youth from an out-of-home placement, on a timeline to be determined by the Missing Persons Coordinator based on the risk assessment for a particular youth.

19. Establish the role of an Indigenous Liaison within the HPS. This position would be filled by an Indigenous police officer whose responsibilities would include outreach and engagement with First Nation and Indigenous communities.

20. Review the process and criteria for issuing a media release to ensure that, where appropriate, timely media releases are issued in missing person investigations, and that due consideration to issuing a media release occurs within set time periods during an investigation.

21. Provide Indigenous-led cultural competency and cultural safety training to all officers.

22. Work in consultation with residential homes and child and youth mental health facilities like Lynwood to develop a living document for each youth in its care that can be readily shared with police if necessary, in the event that the youth is absent from the residence without permission and a missing person’s report is being filed, and in accordance with the requirements under Part X of the CYFSA.

TO THE MINISTRY OF HEALTH (“MOH”):

23. To support the cultural safety and well-being of First Nations children and young people and in keeping with the Truth and Reconciliation Commissions’ Calls to Action (2015), continue to support a range of Indigenous programs to include Youth Life Promotion initiatives which entail both school and land-based programs, Indigenous Mental Health and Addiction Workers in the Indigenous communities across the province, Mental Wellness Teams, Indigenous Professional Development and Tele-Mental Health.

a. Regularly consult with bands and First Nation communities and Indigenous stakeholders on program implementation and service delivery for new and existing initiatives; and report back within a reasonable period of time.

24. Consider the creation of a multidisciplinary mental health services team approach, (including a mental health case manager) for children and their families to support continuity of care throughout their childhood and to provide broad and supportive care.

25. To support and promote cultural safety for First Nations children and young people, the MOH will fund and support Lynwood and similar facilities to engage Indigenous experts to develop and assist in implementing culturally relevant mental health services and supports that reflect the unique needs and well-being of First Nations children and young people.
26. To address the mental health needs of children and young people, the MOH should fund mental health services to address funding shortfalls resulting from the multi- year freeze of Lynwood base-funding.

27. Fund a full range of Indigenous-led mental health services and facilities in the Hamilton region and other regions in Ontario to meet the need for culturally safe and restorative mental health and healing services for Indigenous children, youth and families.

28. Increase sustainable and equitable funding for community-based children’s mental health services, including residential placement options and family support, that are responsive to recruitment and retention needs of service providers to employ multidisciplinary staff and professionals and programs that are flexible, responsive, and facilitate the right services at the right time for children and young people with complex needs.

TO THE CHILDREN’S AID SOCIETY OF HAMILTON:

29. To support the well-being of children, continue to ensure that, as part of the intake process, staff acquire and review all relevant information and documents relating to a young person, including any plans of care developed by prior residential facilities and any information relating to suicidal behaviour or ideation. If there is any information relating to suicidal behaviour or ideation, it must be flagged so any other society workers are immediately aware of that aspect of a particular young person’s history.

30. To ensure the safety of children in care, train staff to ensure that, to the extent a youth’s file is transferred from one staff member to another, all information relating to a young person’s suicidal behaviour and ideation is clearly flagged in transfer discussions or communications between staff.

31. To ensure open and full communication, data collection, knowledge, and relationship-building regarding the children, youth, and families transferred to ongoing service, consider implementing a “one care team per family” system with consideration to the file loads of workers.

32. For young people in care, engage with any outside service provider at the intake stage to set clear lines of responsibility regarding communication of information regarding the young person to those in the youth’s circle of care, including communication of self-harm attempts and leaving the property without permission.

33. Continue to facilitate learning events related to the youth presenting with complex suicide needs and remain an active community participant in the Youth with Complex Suicide Needs (“YCSN”) protocol, a comprehensive and coordinated approach to care for children and youth who have been identified as being at high risk for suicide and have complex presentations.

34. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care.

35. In partnership with the urban Indigenous community, continue active membership on the Indigenous Child Welfare Collaboration Committee established in January 2018 to strengthen relationships, develop pathways and strategies for a coordinated approach to services and wraparound support for First Nations Inuit and Métis children and families involved in child welfare services in Hamilton.

36. Enhance procedures for increasing communication and service coordination contained within the signed protocol between child welfare services and the services provided by urban Indigenous agencies, including but not limited to: De dwa da dehs neye>s (Aboriginal Health Centre), Hamilton Regional Indian Center, Niwasa Kedaaswin Teg, the Native Women’s Centre and the Niagara Peninsula Aboriginal Area Management Board (NPAAMB).

37. Continue to prioritize the Child Welfare Sector Commitments to Reconciliation by transparently sharing data (without personal information and in accordance with Part X of the CYFSA) related to the following outcomes with Indigenous service partners: reducing the number of First Nations children and young people in care, reducing the number of legal files involving First Nations children and families, and increasing the number of formal customary care agreements.

38. Continue to be accountable to the child, the child’s family and the child’s First Nation community to ensure First Nations children in out-of-home placements maintain connection
p.to family, community, and culture and that plans are reflective of the child’s physical, mental, emotional, and spiritual identities through the regular review of all First Nations children in care.

39. Enhance policies and procedures to support collaborative communication and planning with First Nations communities when providing services to an Indigenous family/child/youth by building upon the work of the specialized Indigenous service team, the Sharing Circles for Indigenous youth in care developed in partnership with Catholic Children’s Aid Society, the Hamilton Regional Indian Center and Niwasa Kedaaswin Teg, and the recommendations from the Society’s Child Death Update (Exhibit 24).

40. Recognize that the best practice is to consider Indigenous Dispute Resolution by connecting with the First Nation regarding any challenges faced by a First Nations young person and/or family.

41. Continue to ensure that all young people in care have reasonable access to cell phones or other technologies they may need to communicate with their family, their First Nation and others important to them.

42. Continue to prioritize the recruitment, hiring, and retention of workers with First Nations identity and from other equity-deserving groups, recognizing skills related to Indigenous knowledge and cultural identity alongside traditional mainstream credentials.

43. To support ongoing consultation, communication, and transparency between the Society and the bands and First Nations communities of the children and youth it serves, the Society shall reach out to those bands and First Nation communities and offer to develop a communication protocol and offer to initiate quarterly reviews regarding all children receiving services from the Society.

TO LYNWOOD CHARLTON CENTRE:

44. To ensure the safety of the children in its care, Lynwood’s psychiatric nurse practitioner shall meet with staff upon admission of each new client regarding any diagnosis and/or mental health needs.

45. To ensure the safety and ongoing wellness of the children in its care, where a youth has disclosed suicidal behaviours or ideation, make best efforts to bring together all those involved in a youth’s circle of care to discuss and assess the youth’s situation and participate in safety planning for the youth (including the youth’s self identified support, youth’s guardian, First Nation if applicable, medical team, supportive community members and family where appropriate).

46. To ensure proper coordination with the Hamilton Police Services (“HPS”), maintain a living document for each young person in its care that can be readily shared with police if necessary. Information shall include a recent photograph of the youth, any history of suicide ideation or attempts, known triggers including any incidents of bullying.

47. For a young person in its program, engage with the guardian at the intake stage to set clear lines of responsibility regarding communication of information regarding the youth to those in the youth’s circle of care, including communication of self-harm attempts and leaving the property without permission.

48. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. Where possible and financially feasible, connect young people with external resources that could provide additional opportunities, including but not limited to sport, land-based learning, culture, art, and other pursuits that will assist in developing a forward pathway.
49. Ensure that all safety plans are written down and shared with Lynwood staff, the young person’s guardian, and other members of a young person’s circle of care where appropriate and consistent with privacy legislation and rights.

50. In consultation with the Hamilton Police Services, as well as residential homes and other child and youth mental health facilities, develop a common joint responsibility protocol governing the process, roles, and responsibilities when it comes to searching for youth who have left congregate settings without permission. The protocol should address:

a. the circumstances in which a missing persons report should be filed;

b. the information to be provided as part of that report;

c. the residential home’s responsibilities prior, during, and after filing a report (including conducting a property search where appropriate);

d. the HPS’ responsibilities prior, during, and after filing a report; and,

e. responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth.

51. Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide.

TO THE CHILDREN’S AID SOCIETY OF HAMILTON AND LYNWOOD CHARLTON CENTRE:

52. Develop workable practices to improve contact and connection of individual young people with safe adults in their circle of care, to reduce circumstances where children are absent and their whereabouts are unknown.

53. Promote and utilize the participation of young people and youth-driven practices in services, tools and programs, such as: the Wise Practices resources and Life Promotions toolkit by Indigenous youth, that are about their own wellness and make space for the young people to put into practice tips and ideas from those services, tools and programs.

54. When non-Indigenous service providers are providing care, the First Nation Mental Wellness Continuum Framework should be considered when developing and delivering services to Indigenous children in care.

55. Foster and support the co-development of life promotion programs such as Promote Life Together (“PLT”) between Indigenous and non-Indigenous stakeholders to establish and develop meaningful programs and services, with an emphasis on the inclusion and engagement of Indigenous stakeholders from inception.

56. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights.

TO THE OFFICE OF THE CHIEF CORONER OF ONTARIO:

57. In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns.

58. Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests.

TO ALL INSTITUTIONAL PARTIES:

59. That the MCCSS and all institutional parties to this inquest work together in a collaborative manner towards ensuring that First Nations children have a right to return to their home communities when receiving services under the CYFSA. This should be adopted and developed as “Devon’s Principle”.

TO THE MINISTRY OF CHILDREN, COMMUNITY AND SOCIAL SERVICES AND THE MINISTRY OF HEALTH AND THE GOVERNMENT OF CANADA:

60. Provide direct, sustainable, equitable, and adequate joint funding from the named Ministries and Government of Canada to First Nations, off-reserve Indigenous service providers, and non-Indigenous service providers serving off-reserve First Nations children, youth and families to increase the capacity for collaboration in the provision of child welfare and mental health services.

61. Implement the Spirit Bear Plan through collaboration with MCCSS, MOH and government of Canada

TO THE MINISTRY OF CHILDREN, COMMUNITY AND SOCIAL SERVICES:

62. In partnership and in consultation with First Nations, provide direct, sustainable, equitable, and adequate funding to First Nations for prevention services, cultural services, and Band Representative Services to service and support both on- and off-reserve First Nations children, youth and families involved in child welfare and in support of children and youth in need of mental health supports pursuant to a needs- based approach that meets substantive equality.

63. In partnership and in consultation with bands and First Nation communities, and affiliated Indigenous stakeholders, provide direct, sustainable, equitable, and adequate funding accessible to children’s aid societies and residential service providers to access Indigenous-led cultural services, culturally restorative practices, cultural competency, and educational supports and other cultural supports within the child welfare system.

64. To improve outcomes for First Nations children and youth, empower and seek to fund bands and First Nation communities and affiliated stakeholders (such as the Association of Native Child and Family Services Agencies of Ontario) to collect data and analyze data to determine whether, and to what extent, child welfare interventions and services are improving outcomes for children and youth.

65. Once the data is gathered and analyzed, in partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, seek authority and any necessary funding to implement and act upon the data recommendations to support better outcomes for children and youth, including seeking the necessary authority to make any legislative and regulatory changes to support changes for better outcomes.

66. Provide support for training and capacity building for children’s aid societies and licensed residential facilities to meet the consultation requirements with bands and First Nation communities under sections 72 and 73 of the CYFSA, including the ability for Indigenous children to return to their home communities to support cultural safety.

67. Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi- independent living arrangements, are available for children and young people receiving services from children’s aid societies and Indigenous well-being agencies.

68. In consultation with civil society child rights experts and Indigenous rights experts, undertake a Child Rights Impact Assessment with respect to all proposed regulations made under and amendments to the CYFSA.

69. To improve outcomes for First Nations children and youth, continue to work through the Child Welfare Redesign Strategy on potential further changes to the funding allocation and the funding model and approach to the child welfare service delivery model, including consideration of developing a prevention and reunification process that focuses on family preservation, family reunification, kinship preservation, family contact, assessment of child, youth and parent strengths and needs, parenting skills, home management and routine, infant care, and exploring and developing support networks.

70. In order to support fulsome assessment, information sharing within the child welfare system and ensuring a holistic approach to caring for children and young people, develop future amendments to O. Reg. 156/18 that would improve service coordination, service integration and oversight as part of implementation of the Quality Standards Framework, including:

a. development of an integrated Plan of Care focused on the social determinants of health for the family and child that follows them through community services when they are in the community and also when they are in the care of a children’s aid society and incorporate the cultural and spiritual needs of the child; and,

b. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission.

TO THE MINISTRY OF HEALTH AND TO THE MINISTRY OF CHILDREN, COMMUNITY AND SOCIAL SERVICES:

71. Work with Indigenous communities to support the creation of residential treatment options that are Indigenous-run and Indigenous-informed with Indigenous-specific programming. These would keep Indigenous youth within their local community and connected to family, culture, and local supports.

72. In partnership with children’s mental health residential service providers, develop and effectively fund programs that are responsive to the needs of hard-to-serve young people presenting with high-risk behaviors such as aggression or suicidal ideation and other complex needs. These programs must also consider service coordination when a young person transitions to a new community to avoid the young person being placed on a waiting list to receive assistance.

TO THE ONTARIO ASSOCIATION OF CHIEFS OF POLICE:

73. Consider extending the recommendations 10-22 to include all municipal police forces across Ontario.

TO THE MINISTRY OF CHILDREN, COMMUNITY AND SOCIAL SERVICES:

74. Develop an expert panel including Indigenous leaders, researchers, as well as leaders from other provincial child welfare ministries, such as British Columbia’s Ministry of Children and Family Development who can provide expertise on best practices to revise the child welfare funding formula to address the needs of Indigenous youth. In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities.

75. The same expert panel as noted above should provide recommendations to define outcome measures which clearly describe the successful progression of Indigenous youth through the welfare system to independence and adulthood. These outcome measures should be supported by key performance indicators (KPI) that are measured and updated on a quarterly basis in collaboration with Provincial child welfare agencies. These KPIs will be used to assess performance and efficiencies within the agencies and support ongoing quality improvement initiatives.