Open this photo in gallery Pam Freeman takes a moment to breathe when overcome with emotions surrounding the loss of her grandson, Devon, a 16-year-old from Chippewas of Georgina Island First Nation, died by suicide and was found in 2018 on his group home’s property, nearly seven months after his disappearance from the Hamilton-area facility. Tijana Martin/The Globe and Mail

The Ontario government is facing calls from Indigenous leaders, the provincial NDP and its former children’s advocate to immediately ensure there are mandatory inquests when children die in care.

In an interview with The Globe and Mail on Thursday, Nishnawbe Aski Nation Grand Chief Alvin Fiddler pointed to the death by suicide of a First Nations teenager in the child welfare system as an example of a tragedy that unfolded in a place where children are sent to be kept safe.

Devon Freeman, a 16-year-old from Chippewas of Georgina Island First Nation, died by suicide and was found in 2018 on his group home’s property, nearly seven months after his disappearance from the Hamilton-area facility.

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Devon’s family and community are making an appeal to the provincial coroner’s office for an inquest, saying the process could result in recommendations to prevent future deaths of children in care.

Inquests in Ontario must meet criteria, including if a death occurs at a construction site or while a person is in custody.

In Ontario, child protection services are provided by children’s aid societies and governed by the Child, Youth and Family Services Act while the ministry provides funding to and monitors the societies.

“It is heartbreaking to hear his story and read about his tragic life and death," said Mr. Fiddler, whose organization represents 49 First Nations communities within Northern Ontario.

Mr. Fiddler said questions such as how and why the death occurred could be pursued through a formal inquest, adding he wants those in a position of authority to make an immediate change to ensure this process is automatic in the province.

He pointed to a May, 2017, resolution passed by chiefs-in-assembly calling for a legislative change to be made to the Coroner’s Act to ensure any death of a youth in care will result in a mandatory inquest.

Children in care are supposed to be looked after, Mr. Fiddler said, pointing to deaths of other children from Northern Ontario First Nations in recent years. “Their lives come to a very tragic end," he said. “We need to look more into the systemic failures in how these deaths occur and to find answers.”

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Mr. Fiddler is not alone in his call for mandatory inquests for children who die in care.

Irwin Elman, the former provincial children’s advocate, is also calling for the province to ensure the process is triggered automatically.

Mr. Elman’s office was eliminated by the Ontario government in November, 2018.

Children who die while in the province’s care do so “on all our watch," Mr. Elman told The Globe on Thursday, adding that they must be given a “voice in their death through an inquest.”

NDP MPP Sol Mamakwa, his party’s Indigenous relations critic, said Thursday he, too, supports mandatory inquests for children who die in the child welfare system, which he describes as colonial. “We have to give them [children] a voice,” he said.

In response to the concerns, a spokeswoman for Children Minister Jill Dunlop said Thursday the ministry and Office of the Chief Coroner follow a joint directive in the event of a death, adding it must be followed by children’s aid societies to identify, where possible, opportunities to prevent future tragedies.

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The Ontario government has been undertaking an “extensive review” of the child welfare system, including services that are culturally appropriate, added the minister’s director of communications Hannah Anderson.