We, the jury submit the following recommendations for consideration:

Access to Resources
1. The provincial government should follow the principle of entitlement to service for all children and youth with developmental disabilities and mental health challenges. Client access to services should be available province-wide and not be primarily prioritized according to the region in which they live.

Funding
2. That the Ministry of Community, Family and Children’s Services fund Children’s Aid Societies for the actual cost of purchasing and/or delivering group and individual care within their respective regions instead of using a provincial average. Funding should be based on the principle of entitlement.

Continuum of Services
3. That the Ministries’ of Community, Family and Children’s Services, of Health and Long Term Care and, of Education create within each region, an integrated continuum of services that addresses transition periods from preschool through to adulthood, for children and youth with complex special needs including dual diagnosis. Service categories for consideration are as follows: regional accessibility; flexible, professional in-home supports; case management supports; parent relief (provided in the home); respite care (provided in residential facilities in the community); shared care (a combination of parental and foster care); full-time residential care and; timely access to education at community schools.

Regional Centers of Expert Care
4. The Ministry of Health and Long Term Care and the Ministry of Community, Family and Children’s Services should support the additional development of expert assessment and treatment centers for children and youth with complex special needs and dual diagnosis, in each region of the province not currently serviced. Each regional center should provide a range of on-going services that support community-based and residential programs including the availability of a behavioral therapy consultative service for group homes and each regional Children’s Aid Society. In addition, consideration should be given to the development within these regional centers of a crisis response service.

Consultative Expert Forum
5.  That the Ministry of Community, Family and Children’s Services, the Ministry of Health and Long Term Care and, the Ministry of Education, establish a mechanism to create an expert, second opinion forum for exceptional cases, to provide case consultation and advice, to the entire team providing care to a child or youth. This consultation would be available in situations in which the care and treatment is not effective in achieving safe behaviour management on a continuing basis, and where the safety of the child, staff and, other children is being jeopardized. This mechanism would allow the creation of such forums on a timely basis, drawing upon professional expertise throughout the province.

This expert, second opinion forum would include the following professionals not involved directly in the case, drawn from a central list of such persons who have agreed to contribute to this resource: a facilitator, a psychiatrist with the requisite expertise, a behavioural management therapist, a psychologist, an expert in child and youth or developmental services work (with both practical and theoretical experience), a social worker, and any other appropriate experts as deemed necessary. A representative of youth in care and the Child Advocate’s Office should participate in this forum as a matter of course.

The forum would be publicized and accessed according to established criteria: by the case manager, parent, legal guardian or the treatment team, or the reviewer of the Serious Occurrence Reports on restraints.

The forum may also be accessed by the Coroner or the Coroner’s Pediatric Death Review Committee, as required.

Licensing
6. That the Ministry of Community, Family and Children’s Services require as part of the annual licensing process, that employees of all residential facilities have on their human resources file, current qualifications with respect to training in:
cardiopulmonary resuscitation, first aid and a Ministry approved behaviour management intervention training program.

7. That the Ministry of Community, Family and Children’s Services review all annual Serious Occurrence Report summaries for all licensed group homes as part of the licensing review process. In addition, should client care questions be noted during the licensing review, this information should be forwarded to the appropriate Ministry Program supervisor. If required, the Child and Family Services Act should be amended to facilitate the sharing of pertinent inter-departmental information.

Plans of Care
8. To all residential service providers, Plans of Care need to be developed and communicated within a supportive and positive, goal-oriented context. The “ whole child as a person, with strengths and unique qualities” is paramount.

9. To all residential service providers, Plans of Care should include individualized behaviour management intervention strategies that are consistent amongst all care providers (day treatment and residential) for that child/youth. The behaviour management intervention portion of the Plan of Care should be in a standardized format, province-wide. Thresholds, indicating the need for a case conference or an emergency/crisis response, should be indicated for each individual child/youth. All deviation from the Plan of Care must be documented. This format will assist with client care, employee initiative, licensing and, quality assurance.

Quality Assurance
10. That licensed residential service providers develop a quality assurance program to evaluate adherence to policies, procedures and standards of care. Results of the quality assurance reviews should be documented and reported to: all employees and residents, and be made available to placing agencies.

11. The Ministry of Community, Family and Children’s Services should consider their funding and consultative role in the development of quality assurance, as thç goal would be to incorporate quality assurance into the licensing process for all residential service providers.

Restraints 
12. All residential and day treatment providers should review the significant dangers of ‘prone restraints’ with staff. The training should be designed to promote and strengthen de-escalation skills and to teach physical intervention techniques that avoid the prone restraint position.

13. All licensed residential facilities must record in their policies and procedures, the consequences of staff failing to comply with the approved behaviour management intervention program. Failure to comply would be identified through supervision, Serious Occurrence Reports, residence and CAS agency reporting mechanisms, and quality assurance monitoring.

14. All licensed residential care facilities, day treatment and applicable Ministry of Education programs be legislated to develop an internal “Restraint Review Committee”. Terms of reference should include the expectation that all training be evidence based; that evaluations of knowledge and skill be competence based; that the committee has a clear mandate to monitor restraint use and take appropriate corrective action.

15. Following the implementation of the April, 2003 restraint regulations of Serious Occurrence Reports, the Ministry of Community, Family and Children’s Services consider the development of standardized restraint and crisis response thresholds for incorporation into policy. We recommend Ontario data and evidence-based research be the basis for this policy.

16. Where, in the opinion of the Ministry of Community, Family and Children’s Services, there are reasonable concerns regarding improper use of restraints, the Ministry shall conduct a full investigation. If concerns are not alleviated following thorough investigation, the Ministry shall be required to report any reasonable concerns regarding the improper use of restraints in a licensed group home to all Children’s Aid Society agencies who have children or youth placed in the licensed group home in which this concern has arisen. To acquire this level of integrative communication, legislative change and br proclamation of current legislation is necessary.

Training and Education
17. That Children’s Aid Societies ensure social workers assigned to persons with complex special needs, dual diagnosis and/or developmental disabilities have appropriate specialized training. The training would further enable communication with respect to quality of care and, the assessment and monitoring of the plan of care for adequacy and effectiveness of child/youth services provided.

18. That University and Community Colleges in the Province of Ontario providing post-secondary education in Human Services have, as part of their curriculum, First Aid, Cardio-Pulmonary Resuscitation and an approved crisis de-escalation and intervention training program as mandatory courses within their first year program. That such training be revisited each year of study.

19. That University and Community Colleges in the Province of Ontario providing post-secondary education in Human Services have, as part of their curriculum development plan, a Panel, or Advisory Board comprised of active agency representatives (including youth in care) that will assist with insight into current field experiences and future trend indicators including the need for additional qualified staff. Planning should involve the setting of specific training and continuing education targets with particular emphasis placed on ensuring that a broad knowledge of the challenges of child and youth with developmental disabilities, combined with mental health problems (dual diagnosis), be acquired by all and that specialists be trained and supported. Consideration should be given to the regulation of standards for education and training.

Research
20. That the Ministry of Community, Family and Children’s Services support Ontario-based research into the effective and safe use of restraints in general and into alternative non-intrusive methods of behaviour management. In addition, research should focus and evaluate issues pertaining to children and youth, and the effectiveness/non-effectiveness of each of the approved training curriculum(s), as well as any unknown long-term effects of use of restraints.

21. Consideration should then be given to policy endorsement of one approved behaviour management intervention program. This is to prevent program cross-training confusion and ‘program drift’ that could result in the use of improper or dangerous restraints in a crisis situation. 

Communication
Rationale:
Throughout the Inquest proceedings there was evidence to suggest that there were many barriers to the sharing of information that may have had an adverse impact on client care. So that these issues will be addressed, for the benefit of all children and youth in care, we recommend that:

22. The Child and Family Services Act be amended to give the Ministry of Community, Family and Children’s Services the authority to make available to all Children Aid Societies the following: serious occurrence reports, annual serious occurrence report summaries, licensing reports and any other information it deems relevant to the safety of children and youth in care, and the Office of Child and Family Service Advocacy. This information should be disclosed in a form that does not reveal the name or other personal information of individuals, except where the Ministry deems appropriate to protect the best interests of children.

23. The Child and Family Services Act be amended to require the Ministry of Community, Family and Children’s Services to notify all CAS Agencies with a child or youth in the care of a particular licensed group home where, in the view of the Ministry, there are reasonable grounds to believe that the safety of a child or youth is at risk in that home.

24. A CAS Agency be required to notify the Ministry of Community, Family and Children’s Services and other CAS Agencies where, in its view, there are concerns regarding the quality of care a child or youth is receiving in the home and/or there are reasonable grounds to suspect that the safety of a child or youth is at risk.

25. The Ministry of Community, Family and Children’s Services direct, where applicable, the supervising CAS Agency worker to ensure that pertinent information regarding the ongoing status of the child or youth is being shared between all treatment providers on a regular and timely basis.

26. Absent any reasonable protection concerns, parents who have access to the child should have, on request, access to the following documents: Plans of Care and Serious Occurrence Reports from the licensed group home or Children’s Aid Society agency.

27. The licensing and program supervision departments within the Ministry of Community, Family and Children’s Services report to the same Deputy Minister in the hope that communication will be facilitated for the benefit of all children and youth in care.

Central Database
28. We recommend consideration be given to the formulation of a central database regarding licensed residential facilities, under the auspices of the Ministry of Community, Family and Children’s Services. All information contained therein would require validation. The terms of reference defining the purpose would need to be established. Considerations for inclusion are as follows:

The Ministry should establish a quality review process for all licensed residential facilities, for the collection and compilation of all serious occurrence reports, annual serious occurrence report summaries, licensing reports, and results of investigations. The serious occurrence reports and annual serious occurrence report summaries should not make reference to the personal information of particular children. This database shall be accessible by all Ministry offices within the province and all provincial CAS Agencies.

Independent Autonomous Regulatory Body
29. Should recommendation # 28 (central database) not be deemed feasible after comprehensive participant collaboration, consideration should then be given by the Ministry of Community, Family and Children’s Services to the formation of an independent, autonomous regulatory body that would encompass:
• responsibility for quality assurance,
• licensing of residential facilities,
• ongoing development and revision of service delivery standards and evidencedbased practices focused on client outcomes and results,
• provision of direction to individual residential care providers on service delivery and agency management practices, and improvements that may be required to meet provincial standards,
• analysis and further exploration of serious occurrences and, where appropriate, the development of strategies for corrective action,
• investigation of concerns regarding care and services delivered by the program to residents, and appropriate corrective measures,
• setting of standards for staff qualifications at both the front line, supervisory and management levels and training expectations for the same and,
• annual evaluation of programs (incorporating input from agencies, parents, and the children/youth using them),

Pursuant to the suggested development of the preceding regulatory body, a clear role of the Ministry of Community, Family and Children’s Services would need to be defined within the continuum of the children’s services. This role would include policy development and system management focusing on legislation, direction setting, clarifying of expectations, funding, ensuring value for dollar, and empowering the Independent Autonomous Regulatory Body to set and enforce standards of care and promote Quality Assurance.

Accountability
Rationale:
We, the jury, have reviewed a number of reports and previous jury recommendations that have in large part not been addressed by the government. We forward the following recommendation for consideration in the hope that children and youth will benefit from it and that future juries will not need to re-visit prior recommendations.

30.  The Ministry of Community, Family and Children’s Services, Integrated Services Division, review and implement, with a view towards policy and standards development, pertinent recommendations from the following:
• “Voices From Within: Youth Speak Out”, with particular attention to Section five, regarding Best Practices, (April 1998),
• report from the, “Intersectoral / Interministerial Steering Committee on Behavioural Management Interventions For Children and Youth in Residential and Hospital Settings “, with particular attention to section 4.2, Best Practice, (March 31, 2001),
• “Peel Region Special Needs Children Profile Review “, (May 1, 2002).
•  Inquest Recommendations; W. Edgar, *
• inquest Recommendations; J.D. Durnford. *
 

* We also understand that the Minister has yet to respond to these two Inquest Recommendations