One morning in July, Tim filled his van with camping gear and drove north from his home in London, Ontario, toward Algonquin Park. He knew this route well. Every summer, Tim, 60, and his daughter Jade spent weekends together in the rugged terrain, fishing and hiking. This year he was traveling alone, his van was quiet, without Jade's chatter. A vial containing her ashes rested in a glass holder next to him.
It was Tim's first summer without his daughter, and he planned to bury her remains in the place where she had seemed like herself during the last few tumultuous years of her life.
But when Tim got there, he couldn't let go. He decided to keep the bottle for himself.
“I decided that was all I had left,” he said.
For the past year, Jade's adoptive parents, Tim and Mona, and her birth mother, Nicole, have been struggling with their devastating loss. They hoped Jade's story would force the government to take action. Instead, their efforts to achieve accountability have so far been in vain.
Ontario's Child Death Review Committee has decided not to conduct a systematic investigation into the circumstances that led to Jade's death, her parents recently learned. This choice was met with disappointment and fury by her family and many members child protection sector. Jade's supporters say the investigation is a vital step in identifying systemic problems and preventing similar deaths.
What worries Jade's parents most is that the systems designed to protect children like their daughter remain in free fall. After Jade's death, the children's aid society responsible for her care placed 20 more children in hotels.
“I just feel like the government doesn’t care about these kids,” Mona said. “It's probably better for the government if they die.”
During her year in motels, Jade ran away multiple times, became addicted to hard drugs, and was hospitalized after multiple overdoses and a brutal attack. (To comply with a court-ordered publication ban under the Youth Criminal Justice Act, the Star used the middle names of Jade and her family members.)
The coroner recently confirmed to Jade's parents that the provincial Child Death Review Unit (CYDRA) had reviewed the summary of her death but would not be conducting a deeper investigation. CYDRA also decided not to use its powers to commission the London and Middlesex Children's Aid Society to carry out an independent internal review.
“This case requires a full investigation,” said Irwin Elman, who was Ontario's children and youth advocate until Premier Doug Ford's government eliminated that role in 2019.
In the event of the death of a child or young person in the care of CAS within the last 12 months, the agency must provide a summary death report and each of these reports is reviewed by CYDRA. But few lead to a full-fledged investigation aimed at making recommendations to better protect children.
Last year in Ontario, CYDRA reviewed the records of 122 children who died while in CAS care or in the following year, but published systematic reports on only six children, according to data obtained from the coroner's office.
This means that only 5 per cent of child deaths last year resulted in deeper CYDRA investigations, compared with 20 per cent in 2015, when there were fewer deaths overall.
A spokesman for Ontario's chief coroner, Dr. Dirk Haier, said his office cannot comment on individual cases, but noted that several bodies have the power to initiate reviews or investigations, including ministries responsible for health and child welfare.
The Minister for Children, Communities and Social Services could order the Children's Aid Society to carry out an internal review, but failed to do so. A spokesman for Minister Michael Parse, who has declined several requests for an interview about the storage of children in hotel warehouses, said in a statement that it would be up to the coroner's office to decide whether further review was necessary and noted that the provincial ombudsman could also conduct an investigation.
Elman said each of the agencies responsible for investigating child deaths could and should investigate what happened to Jade and make recommendations to change the situation.
Otherwise, he warned, “in death, Jade will remain as silent and dishonored as she was in her short life.”
Jade's death 'swept under the rug'
Jade was diagnosed with several mental health and developmental disabilities and became a ward of the province after her adoptive parents and then her birth mother transferred custody to London CAS because they could no longer safely manage her needs and behavior at home.
In the weeks after Jade's death, London CAS staff expected the department or coroner's office to order an internal review into child deaths led by an independent expert. Several workers, who spoke to the Star on condition of anonymity because they could be fired for discussing their work, said London CAS staff would welcome an internal review even if their own actions were scrutinized.
For these workers, as for Jade's family, a systemic inquiry would force the province to take a closer look at the constellation of issues that contributed to the teen's death: the employment crisis, the harm she was exposed to while staying in hotels, the lack of addiction programs for youth, wait times for treatment and the challenges her parents faced in obtaining mental health treatment throughout her life.
They were shocked to learn that there would be no investigation.
“It’s her death that is being hushed up,” said one of the workers.
Calls for reform of Ontario's child death review process
There have been calls both within and outside government for an overhaul of the process for handling child deaths.
In September 2024, a month before Jade's death, a report prepared for ministry officials and obtained by the Star warned that the joint directive was “outdated” and “required review.”
The government's website also acknowledges the need for reform, stating that the deadlines have not been updated since 2006 and noting that “there are a number of circumstances that influence and often delay” the process, including that the autopsy and coroner's report can take many months. While CYDRA must decide within 21 days of a death whether to conduct a more in-depth investigation, a spokesman for the coroner's office said that in practice the time frame is “not firm”.
Tim and Jade, who was 12 at the time.
Delivered
Chris Clark, a spokesman for Minister Parsa, did not respond to questions about plans to change the joint directive, but said the government “will continue to strengthen Ontario's child welfare system to ensure all young people can succeed.”
In an email to Jade's foster mother explaining why CYDRA would not carry out a deeper investigation, the regional coroner said London CAS had provided “a comprehensive summary of their involvement, which is very similar to the community's internal review in that it sets out the entire child protection history.”
Children's rights advocates and CAS sources said the reports have nothing to do with formal reviews of child deaths, which are carried out by independent investigators and often lead to a more in-depth CYDRA report with recommendations for changes.
One child protection worker said: “How can (CAS) be trusted to be held accountable?”
Every child death that occurs in state custody should prompt a thorough investigation and public accounting of what happened, several child welfare experts, advocates and workers told the Star.
“The least the state can do is carefully and objectively disclose the truth about the life and death of this particular child so that a similar death does not occur,” said Julie Kirkpatrick, a retired lawyer who practiced in child welfare for 20 years and is now pursuing a doctorate at Carleton University studying young people's rights under the Charter.
“The province has many child mortality review mechanisms in place for children who die in government care,” she added. “Why are none of these options activated?”
After Jade's death, more children were kept in hotels.
Elman, a former Ontario children's and youth advocate, said provincial authorities are spending too much time pointing fingers instead of investigating what happened to Jade.
In an email to the Star, a spokesman for the coroner's office noted that London CAS could conduct its own internal review of child deaths without any instructions.
London CAS told the Star that while it carries out an internal review into every child death, it will only initiate a formal independent review if its internal findings reveal concerns about its work with a young person, rather than because of system failures beyond its control.
“We do not conduct formal internal reviews of child deaths at will if the initial internal review indicates that the cause of death is the result of systemic factors that the agency cannot develop or recommend action for correction,” the agency said.
Following Jade's death last October, the agency confirmed it had placed 20 children in hotels as there were a “limited number” of accommodation options for children with complex needs. Child welfare leaders have been warning the province about the crisis for at least four years, the Star has learned.
This figure astonishes Jade's biological mother, Nicole. “Children who need help should not live in hotels,” she said.
Back in June, Tim approached Premier Doug Ford directly. “Changes need to be made,” he wrote in a text message to Ford’s personal cell phone number, which the premier shares with the public. “Just imagine that this is your daughter.” When Ford answered, they had a short phone call, which encouraged Tim. But nothing came of it.
A discretionary coroner's investigation is another measure of accountability that family members can seek when the death of a loved one causes systemic problems. Jade's parents made a formal request in June and have yet to receive a response. The office did not provide an exact timeline but warned the family that even if ordered, it could be years before it happens.
In late September, Mona contacted the Ontario Ombudsman's Office, which a year ago announced it was investigating the practice of placing children and youth in unlicensed placements. The investigation is ongoing, the department said.
The office staff arranged a phone call with Mona to listen to her concerns. She hopes something good will come out of this, but she's not optimistic.
The Toronto Star investigates how and why children with complex special needs aren't getting the treatment, care and support they need. If you have a story or advice to share, please email [email protected] And [email protected]
