B.C. Coroner Replies to 'Cody's Death' Article

Office of the Chief Coroner

[Editor's note: The Tyee received this letter from Assistant Deputy Coroner Lisa Lapointe following publication of Judith Ince's report on the impending investigation into the mauling death of Maple Ridge toddler Cody Fontaine. Lapointe was interviewed before the story was published, and after submitting this letter stated to The Tyee that Ince's piece contained nothing inaccurate. To read Ince's piece click here.]

In order to assist in a more thorough understanding of the BC Coroners Service activities with regards to investigating and reviewing children's deaths in the province, I am providing the following information:

Effective January 1st, 2003, the BC Coroners Service assumed responsibility for the Child Death Review previously undertaken by the Children's Commission. This enhanced the Coroners Service mandate with regards to children's deaths. In addition to the coroner's mandate of establishing the facts regarding the sudden, unexpected death of a child, the Coroners Service reviews all deaths of children in the care or custody of the Province and all deaths where a child has been receiving services of the government in the year prior to their death.

The process of Child Death Review begins from the time a child's death is reported to the Coroners Service. This review includes:

• Development of comprehensive child death protocols to ensure that each death is investigated in a thorough manner
• Monitoring all ongoing child death investigations in the province
• Liaising with MCFD including access to all MCFD data and files
• Liaising with the Vital Statistics Agency to ensure that all children's deaths are reviewed including those not normally reported to the Coroner (i.e.. natural, expected deaths of children)
• Developing the necessary framework to ensure comprehensive investigations are conducted, including review of services provided by government agencies
• Development of a database focusing on the issues and trends relating to children's deaths in BC, including the preparation of a public report regarding Child Death Review

There is a coroner assigned full-time to the Child Death Review Unit at the Office of the Chief Coroner. In addition to the individual investigations undertaken by the coroners with jurisdiction concerning a death, the coroner in the Child Death Review Unit provides support, assistance and information regarding systemic issues. He monitors any issues and trends and ensures coroners across the province are aware of those concerns relative to the death they are investigating. He also monitors trends and issues regarding the delivery of services to children and their families insofar as they may have had an impact on the death.

A Child Death Review Team, comprised of senior managers in the Coroners Service, meets weekly to review all children's deaths reported in the previous week and to recommend avenues of investigation and specific or aggregate issues of concern. This team also reviews all draft coroners' reports to ensure any outstanding issues have been addressed.

When aggregate or specific issues of concern require more comprehensive examination or expertise, a Child Death Review Committee will be asked to assist in the review. Agency and individual participation in this committee is based on:

• commitment to the health, safety and well-being of children and youth in British Columbia
• knowledge, skill or expertise relating to the issue or topic
• the ability to provide advice/counsel and/or recommendations to the Chief Coroner regarding death prevention

Where systemic issues are identified as requiring review or amendment, they are referred to the office of the Child and Youth Officer; Ms. Jane Morley.  Ms. Morley, her staff, and staff from the Office of the Chief Coroner ensure that these and related issues receive a thorough examination and appropriate follow-up where indicated.

The BC Coroners Service is committed to ensuring all children's deaths in the province are thoroughly and independently reviewed.  When indicated, this will include a review of the provision of government services.

Sincerely,
Lisa Lapointe
Assistant Deputy Chief Coroner
Office of the Chief Coroner