Ninety children known to Ontario's child welfare system died in 2007, according to the latest report from the chief coroner's office – a number the province's new child advocate says is shocking and should trouble us all.

Equally disturbing, says Irwin Elman in his first annual report to the Legislature today, is the government's refusal to share detailed information on these deaths with his office.

"These are obviously very critical documents for the understanding of the events leading to the death of the child or youth, and entirely necessary for the work of the Advocacy Office," Elman writes in the report entitled 90 Deaths: Ninety Voices Silenced. "The matter of access to information is one that we will pursue vigorously."

In an interview, Elman, who has worked with youth in the care of children's aid societies in Toronto for more than 20 years, said he had "no idea" so many of these vulnerable children, who were either open cases of the CAS or had died within a year of their files being closed, could perish in a single year in Ontario. Nor did he know that the number of children who have died has been constant since the late 1990s when the Coroner's office began tracking their deaths.

When he asked medical officers of health and colleagues in child welfare, they, too, were surprised by the number and urged him to speak out, Elman said.

It is why the deaths are highlighted on the cover of his 25-page report, he said, with the face of a child whose mouth is covered by a red banner reading "90 deaths, ninety voices silenced."

Elman notes the deaths represent less than a quarter of all children who died in the province in 2007 and are a fraction of the 26,260 open cases of children's aid societies. But the number of deaths is "too high by any standard."

"These are children that we, as a province, have determined are in some peril and should be receiving the best of what we, as their parents, have to offer," he said. "So how could 90 of them die? I want all of us to be thinking about that."

Gaining more access to information about children and youth involved in the child welfare and youth criminal justice systems, and broadening his office's legal right to the coroner's files on deaths are key goals this year, he said.

"We need (this information) to help resolve issues that youth have contacted us about, to know how to respond to incidents involving children and youth in care and to investigate any deaths among our charges," his report says.

The 90 deaths in 2007 are recorded as part of the chief coroner's annual Pediatric Death Review Committee report released last June. They include children and youths in foster care, whose families had open files with a children's aid society or had died within a year of their files being closed.

Most of the deaths were preventable, the committee concluded.

Sixteen were accidental; nine were listed as suicides; four were homicides; eight died from natural causes and could probably not have been prevented; 22 were considered undetermined, which means there was no evidence for any specific classification or they fit within more than one classification; 17 are yet to be assigned a classification; and 14 were not considered appropriate by the Coroner for investigation because their deaths were expected due to fragile health.

Of the 76 classified deaths, 34 were babies younger than one year old and 24 were youths between the ages of 12 and 18.

The report provides broad geographical information about where in the province the children died, but there is no information about ethnicity, family income and community resources, or if the child was in foster care or living with parents. (In an interview, a spokesperson for the coroner's office said 14 of the classified deaths in 2007 were children in foster care.)

Prevention strategies suggested in the coroner's report include safer sleeping arrangements for babies; co-ordinated mental health services for youth; better supervision; educating caregivers early in a baby's life to be more mindful; and paying more attention to children's medical needs.

Elman says his office must focus on the deaths and strive to understand the circumstances – broad and specific – to ensure the children are safe and thriving.

"I would like to honour the kids who died by looking at their journeys and using them to help the living in as broad a sense as we can," he said. In his report, Elman says his office will request legal standing at all inquests into deaths of children in the system and will conduct an independent review of jury recommendations dating back 10 years to determine trends and gaps.

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The office receives about 3,000 phone calls for help each year from among more than 20,000 children and youth in contact with Children's Aid. Those in foster care are there because of parental neglect or abuse and many feel their lives are spinning out of control, the report says. Worse, many say the stigma of being connected to the system is overwhelming.

Elman wants his office to do more to reach out and give these children a voice and a role in improving their lives. And he hopes to form regional youth reference groups so their concerns can be heard.

The report includes a section and letter addressed directly to children and youth in care, advising them of their rights and urging them to phone the office – collect if they can't access the 1-800-263-2841 number – if they need help.

"Children and youth like you have overcome tremendous barriers in the past to become loving parents, lawyers, professors, plumbers, artists, activists – you name it," Elman writes. "We are here to help you with the hard work and courage needed for you to take the risks to overcome barriers you face," he adds. "I intend to lead an office ... that demonstrates each day our belief in you."

The office will work to implement Jordan's Principle – named for a First Nations child in Manitoba – which aims to ensure conflicts over which level of government has financial responsibility to help a status Indian or Inuit child are settled after the service is provided.

For Northern Ontario, where only one advocate fields calls from 15 child welfare agencies, the report said the office will appoint a special director or deputy provincial advocate to consult with the community on how best to proceed. New measures, which likely won't take effect until later in the year, would need additional funding, the report says.

The child advocate's annual budget when the office existed as part of the provincial ministry of children and youth services was $1.8 million. But it will top $3.9 million in this, its first year as an independent office.

Still, the report notes that with a staff of just 21, including 13 advocates, Ontario has the smallest per capita staff and budget of any provincial children and youth advocate's office and may need more resources in the future to fulfill its mandate.

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