The safety of children and youth is being threatened by the “confused” and incomplete reporting of serious incidents in residential care.

Those are the findings of a new report by Ontario’s Advocate for Children and Youth into the province’s troubled system of residential care.

The sloppy reporting of serious incidents, the report says, undermines a key government mechanism that monitors and assesses the safety of kids in settings such as foster care, group homes and mental health treatment centres.

The report — co-authored by provincial advocate Irwin Elman and Ryerson University professor Kim Snow — analyzed the “serious occurrence reports” that must be filed to the Ministry of Children and Youth Services.

During a three-month period beginning January 2014, 4,839 serious incidents were reported in residential care settings across the province. All but 800 of them involved kids in the care of Ontario’s 47 privately run children’s aid societies.

Almost half the occurrences, a stunning 48.7 per cent, resulted in kids being physically restrained, which usually involves staff wrestling them to the floor.

In 31 per cent of those reported restraints — 737 incidents — the physical force was applied against young people with developmental disabilities. With these youths, the physical restraint often included the use of prescribed medication and sometimes the help of police.

Yet key information about restraint incidents is missing from many reports. That makes it impossible to know if staff followed ministry regulations, which say restraints should only be applied when there is a “clear and imminent risk” that a young person will injure himself, or others.

“At times it is unclear what the threat was that staff perceived, or if de-escalation was attempted,” the report says. “It also seemed in some reports that non-compliance by a young person to a direction by staff is the precipitator of the restraint.

“This is very concerning because it is directly contrary to the regulations governing the use of physical restraints.”

Most of the restraints were brief, but “some lasted hours, involved police, and at times became so unsafe that they were aborted,” the report says, adding that some young people are restrained multiple times in a short period.

Elman has given the report to a panel of experts appointed by the provincial government to examine Ontario’s system of residential services. The panel will submit its report to the Ministry of Children and Youth Services next week.

The panel began its work after an ongoing Star investigation revealed high rates of youths in care being restrained in group homes, and police often being called on kids who break house rules or damage property.

On average, 15,625 children and youth were in foster or group-home care in 2014-15. In 2014, there were 23,263 serious incidents in residential care settings reported to the ministry.

“In reading the reports, it was often difficult to determine what exactly happened, what was done in response to the incident and what follow up or debriefing occurred after the serious incident had ended,” Elman’s report says.

Part of the problem is the lack of standardized forms for reporting serious occurrences. And the multiple forms being used are often filled with meaningless “stock phrases.” Even the time and date of incidents are often left out.

Stock phrases were even used to describe some of the 19 deaths that occurred in the three-month period, including, “Patient died due to illness. Death expected.” The phrase was used in four deaths.

Allowing an agency to simply report a death as “expected,” the report argues, “deprives (the ministry) of an opportunity to identify situations in which the safety and well-being of children may be at issue.”

“I want to know who was with these children when they died,” Snow said in an interview. “And to think that the government would accept such a report about a child in their care’s death … it’s hard to imagine it was accepted.”

The analysis found 116 incidents where abuse was alleged, and 45 per cent of these allegations were against caregivers, foster parents or staff. Investigations were triggered but in 46 cases, no information of its outcome was provided.

Elman’s office received the three months’ worth of serious occurrence reports from the ministry. But the reports arrived with the sex and date of birth of the young residents redacted. Redacting the ages, the report says, “has the effect of obscuring the frequency with which intrusive measures are used against extremely young children.”

In an interview, Elman said the province should be analyzing data from the occurrence reports in a way that would allow it to identify patterns. The ministry could then say to agencies, “There may be a problem here. There's a trend.'”

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By the numbers

Types of serious occurrences involving children and youth in Ontario residential settings for a three-month period in 2014:

19 deaths

2,354 physical restraints

334 serious injuries

116 abuse incidents witnessed or alleged

994 young people who went missing

16 disasters, such as power failures, on premises

46 complaints about operational or safety standards

1,010 complaints made by or about a resident, or other serious occurrences

The recommendations

Ministry should create a publicly available electronic database of serious occurrence reports.

Ministry should direct that all sections of serious occurrence reports be fully filled out.

The young person involved in a serious incident should be able to report his or her version of events.

Ministry should impose standards on how restraints are to be reported, including a description of what led to the restraint, the length of the restraint and record of any injuries.