Mandatory reviews into child deaths: October 1, 2018–March 31, 2019

Between October 1, 2018 and March 31, 2019, the Advocate received notifications of the deaths of 10 young people who passed away. They were identified as children in need of intervention and were receiving child intervention services at the time of their death or within two years of their death, meeting the criteria for mandatory reviews by the Advocate. A police agency or the Crown Prosecution Service requested stays (holds) on two of the ten notifications. This report contains eight separate and distinct investigative reviews. Each includes a history of the young person’s involvement with government systems, and individual findings, observations and/or recommendations. The Glossary of Terms is provided in Appendix 1. The list of experts and Elders who were consulted is provided in Appendix 2, and the Terms of Reference for the reviews are provided in Appendix 3.