“Rights Unrecognized: Mia’s Story”
Investigation into the adequacy of services provided by York Region Children’s Aid Society to “Mia”
Paul Dubé
Ombudsman of Ontario
April 2024
Office of the Ombudsman of Ontario
We are
An independent office of the Legislature that resolves and investigates public complaints about services provided by Ontario public sector bodies. These include provincial government ministries, agencies, boards, commissions, corporations and tribunals, as well as municipalities, universities, school boards, child protection services and French language services.
Land acknowledgement and commitment to reconciliation
The Ontario Ombudsman’s work takes place on traditional Indigenous territories across the province we now call Ontario, and we are thankful to be able to work and live on this land. We would like to acknowledge that Toronto, where the Offce of the Ontario Ombudsman is located, is the traditional territory of many nations, including the Mississaugas of the Credit, the Anishnabeg, the Chippewa, the Haudenosaunee, and the Wendat peoples, and is now home to many First Nations, Inuit and Métis peoples.
We believe it is important to offer a land acknowledgement as a way to recognize, respect and honour this territory, the treaties, the original occupants, their ancestors, and the historic connection they still have with this territory.
As part of our commitment to reconciliation, we are providing educational opportunities to help our staff learn more about our shared history and the harms that have been inficted on Indigenous peoples. We are working to establish mutually respectful relationships with Indigenous people across the province and will continue to incorporate recommendations from the Truth and Reconciliation Commission into our work. We are grateful for the opportunity to work across Turtle Island.
Contributors
Director, Children and Youth Unit
Manager, Investigations, Children and Youth Unit
Investigators
-
James McGuirk
-
Fred Lwanga
Senior Counsel
General Counsel
Table of Contents
1 In the fall of 2019, 16-year-old “Mia”[1] had at least two critical concerns: Finding somewhere to sleep from one day to the next and a way to finish high school. On September 23, 2019, Mia and her mother argued. According to Mia, her mom “flipped out” and “kicked her out” that day, leaving Mia with no other family who were willing or able to take her in for more than a few days.
2 Mia spent her whole life in the Greater Toronto Area. Her family had a lengthy history of involvement with the child protection system. Her older sister was in the care of a children’s aid society (CAS) by 2015. Mia’s parents did not live together, and she lived mainly with her father when she was younger, but in September 2019, returning to his house was no longer an option. Around age 13, Mia had disclosed to a child protection worker at the Children’s Aid Society of Toronto that he had physically abused her, her siblings and her mother.
3 Mia was in emotional crisis when she left her mother’s house. In fact, her mother told York Regional Police she had commented that she wanted to die. The police called York Region Children’s Aid Society (York CAS), which opened a file on September 24. They considered Mia to be at “high” risk of potential child abandonment or caregiver/child conflict, given her family’s extensive prior involvement with child protection.
4 A York CAS intake worker tried to connect with Mia on multiple occasions, and eventually found out she was living at her grandmother’s house. Before the worker could meet with Mia, however, Mia’s father contacted York CAS with concerns about this arrangement. He felt Mia’s sister, who was then living with the grandmother as well, was a bad influence because of her smoking and drug use. Building security had also recently asked the sister to leave because she was not registered to live at the apartment. Because of this, the father suggested Mia be placed in a foster home.
5 The intake worker finally met Mia on October 8. Mia confirmed she was living with her grandmother and trying to get back into school, but her mother wouldn’t give her the documents she needed to register at a school closer to the grandmother’s house. The worker tried to stay in contact with Mia over the next few weeks, but Mia missed scheduled meetings and couldn’t be reached by phone. On November 7, Mia’s mother called York CAS, concerned that no one knew where her daughter was. When the intake worker managed to speak with Mia on November 8, Mia told her she had been forced to leave her grandmother’s house and was staying with an aunt. Mia said she wanted a foster placement, as her aunt wanted her out and she had no other family or friends to rely on for shelter.
6 Given her immediate housing crisis, York CAS proposed only one option for Mia: A bed in an emergency youth shelter. The worker called several shelters in an unsuccessful attempt to find an opening for her. She then spoke with Mia’s aunt to explain that the only options for Mia were a shelter bed or living on the street. Reluctantly, her aunt agreed to have Mia stay with her until the end of November. But she stressed that this could not be a long-term arrangement, because of limited space and interpersonal conflict between Mia and others in the home.
7 With no other family members available to provide more permanent shelter, Mia and her worker discussed the possibility of entering into a Voluntary Youth Services Agreement, or VYSA. Under the Child, Youth and Family Services Act, 2017 (CYFSA) and a Ministry of Children, Community and Social Services directive, children’s aid societies must provide the “full range” of protection services to 16- and 17-year-olds that are available to younger children. In most cases, this is done through Voluntary Youth Services Agreements. This voluntary support can help 16- and 17-year-olds transfer to independent living, or support them in more traditional foster homes. From the beginning, Mia made it clear to her worker that she was not ready for independent living and wanted the stability and support that a foster home would provide.
8 As the deadline for Mia’s departure from her aunt’s house approached, Mia and York CAS worked on formalizing a Voluntary Youth Services Agreement (VYSA). On November 26, Mia met with a lawyer from the Office of the Children’s Lawyer to discuss the expectations and responsibilities under such an agreement. Meanwhile, the intake worker began the process of finding her a foster home. No suitable foster homes directly affiliated with York CAS were available, but three homes operated by external providers met her needs and had space.
9 Although an end to Mia’s housing insecurity and couch surfing seemed to be in sight, senior management at York CAS ultimately refused to approve any of the external foster placements. Instead, they encouraged frontline staff to keep exploring family options. In one email exchange, the Director of Service even suggested that, rather than the CAS providing her with funding to live in a foster home, Mia could “stay in a shelter.”
10 York CAS entered into a Voluntary Youth Services Agreement with Mia on December 11, 2019. It stated that Mia “wanted support from the Society to assist with stability and to re-enroll in school.” Despite this agreement, York CAS never offered Mia a place to live or any other tangible support before she died suddenly in January 2020.
11 By law, whenever a child dies within 12 months of receiving services from a children’s aid society, it must be reported to my Office.[2] A joint directive between the former Ministry of Children and Youth Services, the former Ministry of Community and Social Services, and Ontario’s Office of the Chief Coroner also requires certain deaths be reported to the Coroner’s Office. The Coroner’s Office determined that Mia’s death was not connected to the child protection services that she received. However, concerns about Mia’s interactions with York CAS were raised with my Office. As well, in November 2020, the Ministry of Children, Community and Social Services completed a report that detailed serious issues with the working culture at York CAS.
12 In October 2021, I launched an investigation into the adequacy of the services that Mia received from York CAS between October 2019 and her death. After my investigation began, York CAS hired an external reviewer to assess the services that were provided to Mia, and I paused my investigation while this review was ongoing. The external reviewer issued a report in May 2022 that determined that the services provided to Mia were largely compliant with the law. It contained several recommendations for improvements, but there were still outstanding areas of concern. Accordingly, I resumed my investigation.
13 My investigation found that despite being eligible for the full range of protection services under the CYFSA, Mia received virtually no support from York CAS. Many staff we interviewed said that an “admission prevention” initiative at York CAS put enormous pressure on staff not to offer foster placements to children. Admission prevention is a laudable goal, intended to ensure that children are supported in their home wherever possible. However, the initiative was applied in Mia’s case without full consideration of her personal circumstances, and her repeated requests for a foster home placement. No one in Mia’s life was willing or able to provide her with a stable living environment, and York CAS failed to offer her an alternative living option or to provide concrete support that may have made it possible for her to stay with extended family.
14 My investigation found that Voluntary Youth Services Agreements were relatively rare at the York CAS. Staff had received limited training in how to administer these agreements and were unfamiliar with how to offer services under them.
15 My investigation also identified serious issues with the way Mia’s wishes and best interests were considered when making important decisions that affected her. The best interests of a child are supposed to be the paramount consideration in all child protection decisions. The Child, Youth and Family Services Act, 2017 gives children receiving child protection services the right to have their voices heard and to participate in decision-making that affects them. Mia wanted – and specifically requested – the stability that a foster placement could provide, and going to a youth shelter bed was clearly not in her best interests. There is no evidence that Mia was able to have her voice heard before York CAS senior management decided to deny her an external foster placement. She deserved better, and it is my opinion that York Region Children’s Aid Society provided inadequate services to Mia from October 2019 until her death in January 2020. This conduct was unreasonable and wrong under s. 21(1)(a) and (d) of the Ombudsman Act.
16 I have made 20 recommendations in this report, aimed at enhancing the services that York CAS offers to 16- and 17-year-olds who are in need of protection. York CAS accepted all of my recommendations, and my Office will monitor its efforts to address the gaps and failures outlined in this report.
17 I also shared a preliminary version of this report with the Ministry of Children, Community and Social Services. Since 2019, my Office has received 90 complaints relating to 30 different children’s aid societies raising concerns about VYSAs. Although the circumstances varied, my Office identified considerable uncertainty and inconsistency surrounding the provision and scope of voluntary protection services offered to 16- and 17-year-old children by children’s aid societies. In its response to my Office, the Ministry recognized the importance of increasing the knowledge of how to use and implement Voluntary Youth Services Agreements in the child welfare sector. It explained it would be working with the child welfare sector, including reviewing the training provided, to enhance knowledge of VYSAs and their administration.
18 Tragically, Mia’s voice went largely unheard when she sought support from York CAS prior to her death. I am encouraged that the recommendations in my report, and York CAS’s commitment to their implementation, will help ensure that other young people seeking and receiving voluntary services won’t have the same experience.
19 In May 2020, my Office received a complaint that the York Region Children’s Aid Society had failed to provide appropriate protection services to Mia from October 2019 until her death in January 2020. The complainant provided us with troubling details suggesting that Mia had been unable to access housing support from York CAS even though she was a child in need of protection.
20 Some details related to Mia’s death had been reported to my Office by the York Region and Toronto children’s aid societies (CASs), prior to the receipt of this complaint. Both CASs were required to inform my Office of this event under O. Reg. 80/19, which applies when a child suffers death or serious bodily harm and has received services from a CAS within the last 12 months. Because these reports focused on the circumstances of Mia’s death, they provided few details about the child protection services she did or did not receive prior to her death.
21 Mia’s death was also reported to the Office of the Chief Coroner.[3] Under the Ombudsman Act, I have the authority to investigate “any” matter concerning a children’s aid society service to a child, except “child deaths that fall within the jurisdiction of the Office of the Chief Coroner or any committees that report to the Office of the Chief Coroner”.[4] The Office of the Chief Coroner reviewed Mia’s death and determined that it was not directly connected with the services provided by York CAS. It also determined that her death would not be further investigated by the Pediatric Death Review Committee or the Local Death Review Table.
22 My investigation focused on the adequacy of child protection services provided to Mia, and not on the circumstances of her death.
23 While we were gathering evidence about Mia’s interactions with York CAS, we learned that the Ministry was also beginning an operational review of York CAS that might relate to similar issues. Our Office closely monitored the Ministry’s review, and after its final report was published in October 2020, I determined there were additional concerns regarding services received by Mia that required investigation.
24 In October 2021, I notified York Region Children’s Aid Society of my intent to investigate the adequacy of services provided to Mia from October 2019 until her death in January 2020. Although my Office initially became aware of Mia’s circumstances through a complaint raising various issues, I launched this investigation on my own initiative to focus on Mia’s story.
25 Prior to receiving my notice of investigation in October 2021, York CAS hired an external reviewer to conduct its own review of Mia’s interactions with York CAS. However, the investigator’s work was delayed due to a review mandated by the Office of the Chief Coroner, and we paused our investigation to give York CAS the opportunity to thoroughly investigate the matter and directly address any concerns that were identified. The external reviewer’s report, finalized in May 2022, determined that York CAS was in “substantial compliance” with applicable legislation, standards, policies, and procedures when providing services to Mia. Although the report made some recommendations for improvement, I continued to believe that there were important issues that remained unaddressed, and we resumed our investigation.
26 My investigation was conducted by staff from our Office’s Children and Youth Unit, who have specialized experience and expertise in child welfare and protection issues. They were supported by members of our Legal Services team.
27 The team conducted interviews with 11 staff and former staff from York CAS, as well as others who had information relevant to the investigation. They included individuals from the Ministry of Children, Community and Social Services, the Peel Regional Police Service, and the Office of the Children’s Lawyer. We also contacted some members of Mia’s family.
28 The investigation team also reviewed numerous documents from York CAS, the Ministry, and the offices of the Coroner and the Children’s Lawyer. These included notes of interactions with Mia and others, internal decision-making, and various reports, as well as relevant policies, internal communications and other documents.
29 Where possible, we sought to incorporate Mia’s voice, as recorded and remembered by those who interacted with her. Because she was only involved with York CAS for a short while before her death, there is little documentation reflecting Mia’s strengths, interests, and individuality. The information that does exist describes Mia as a “brave” young woman who desperately wanted to finish school and who felt she was not ready to live on her own.
30 York CAS, the Ministry and the other organizations we contacted co-operated fully with our investigation.
31 The Child, Youth and Family Services Act, 2017 (CYFSA)[5] governs the provision of child protection services in Ontario. It sets out who is allowed to provide these services, how they must operate, and what the rights of children and youth receiving services under the Act are.
32 York Region Children’s Aid Society (York CAS) is one of 50 children’s aid societies designated and funded by the Ministry of Children, Community, and Social Services (the Ministry). Each is authorized to operate within a specific territorial jurisdiction and may be approved by the Ministry to carry out a variety of functions related to children, such as:
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Investigating allegations or evidence that children may be in need of protection;
-
Protecting children where necessary;
-
Providing guidance, counselling and other services to families for protecting children or for the prevention of circumstances requiring the protection of children;
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Providing care or supervision for children; and
-
Placing children for adoption.[6]
33 All Ministry-designated children’s aid societies (CASs) are subject to the CYFSA as well as its accompanying regulations. Among other things, the Act obligates CASs to follow prescribed standards of service, procedures, and practices.[7]
34 As a designated children’s aid society, York CAS is tasked with providing the full range of services under the CYFSA in accordance with these rules.
35 Children’s aid societies must respect children’s rights when providing services. The preamble to the CYFSA begins with an acknowledgement that “children are individuals with rights to be respected and voices to be heard” and a commitment to providing “child-centred” services to children and their families.
36 To achieve these goals, the CYFSA sets out specific rights for children receiving services under the Act. Relevant to this investigation, section 3 provides children with various rights, including the right:
-
To be engaged through an honest and respectful dialogue about how and why decisions affecting them are made and to have their views given due weight, in accordance with their age and maturity.
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To be consulted on the nature of the services provided or to be provided to them, to participate in decisions about the services provided or to be provided to them and to be advised of the decisions made in respect of those services.
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To raise concerns or recommend changes with respect to the services provided or to be provided to them without interference or fear of coercion, discrimination or reprisal and to receive a response to their concerns or recommended changes.[8]
37 These rights help ensure that service providers can achieve the paramount purpose of the CYFSA, which is to promote the best interests, protection and well-being of children.[9]
38 In addition to setting out the rights for children receiving services, the CYFSA and its regulations establish numerous requirements for service providers. Of greatest relevance to Mia’s circumstances is section 7 of O. Reg 155/18, which sets out documentation requirements related to decision-making affecting children. It states:
7. A service provider shall document the following in the file of a child or young person for whom it provides a service:
1. How and when the service provider gave the child or young person an opportunity to participate in decision-making about the services provided to or to be provided to them or decisions affecting them.
2. Whether the child or young person participated in the decision and, if they did participate, a description of how they participated and any views they expressed.
39 The CYFSA allows children’s aid societies to provide protection services to all children in need of protection, including those who are 16 or 17 years old. Children receiving voluntary services are entitled to receive the full range of protection services. They are not considered to be children in care unless they receive residential care, which is typically provided through a foster or group home.[10]
40 CASs have only had the authority to provide protection services to young adults since January 1, 2018. Previously, they could only offer services to 16- and 17-year-olds if a court had determined they were a child in need of protection prior to their 16th birthday. At the time of this legislative change, the Minister of Children and Youth Services highlighted how the old system meant that vulnerable 16- and 17-year-olds who needed protection were instead being referred to other community services, like shelters. The Minister observed that when it is not safe for these young people to live at home, they “may have fewer options left to them” and those “who have been abused or neglected have higher risks of experiencing homelessness, mental health issues, substance abuse, violence and human trafficking.”[11]
41 The Minister said that raising the age of protection to 18 was intended to make sure that these young adults would “be able to access services that keep them safe and provide them with the ability to reach their full potential.”[12] Increasing the age of protection was widely supported in the child welfare community, including by the Ontario Association of Children’s Aid Societies, and the change was viewed as so time-sensitive that it was brought into effect months sooner than other legislative reform to the child protection regime in Ontario.
42 CASs have a lot of flexibility in how they provide services to 16- and 17-year-olds, depending on the unique circumstances of each child. In some cases, a children’s aid society may work with the family in the home and make referrals to community services. “Kinship” placements or “customary care arrangements” may also be considered. However, there may be no safe options with family, friends, or close community members. In those instances, section 77 of the CYFSA permits CASs to enter into voluntary agreements with 16- and 17-year-olds to provide services and supports when a youth “is or may be in need of protection” and the CAS is satisfied that other options are not sufficient to keep them safe. These agreements are known as Voluntary Youth Services Agreements, commonly shortened to VYSAs.
43 A Voluntary Youth Services Agreement sets out the responsibilities and expectations of the youth and the CAS, and can be terminated by the youth at any time. They are individual to each youth’s circumstances. Some youths might receive support to live with their families; others to live independently, semi-independently, or in residential placements.
44 The Office of the Children’s Lawyer is an independent office of the Ministry of the Attorney General that represents the interests of children under the age of 18 in child protection cases. At the time Mia was seeking voluntary services, the CYFSA required CASs to notify the Office of the Children’s Lawyer when they planned to enter into a Voluntary Youth Services Agreement.[13] However, the law changed in 2021. It now requires this notification whenever a youth requests a VYSA, even if the CAS does not think it is warranted.[14] Section 77(7) of the Child, Youth and Family Services Act, 2017 allows the Office of the Children’s Lawyer to provide legal representation to youth in each of these circumstances, if the Children’s Lawyer feels it is appropriate.
45 The Ministry has a policy directive that outlines requirements for how CASs must offer protection services to 16- and 17-year-olds.[15] The directive notes that they are to provide the “full range of protection services for 16- and 17-year-olds” that would otherwise be available under the CYFSA. The directive states that the work of CASs should be guided by various principles, including: Ensuring that protection services are youth-centred; the importance of maintaining a youth’s connection to kin, community and culture; the provision of culturally appropriate services for First Nations, Inuit and Métis youth; and taking the least disruptive course of action to protect the youth.
46 The Ministry has produced a variety of communication materials to explain how CASs are to offer services to 16- and 17-year-olds, including two fact sheets.[16] One is aimed at young people; the other at service providers. Both speak to the role of a children’s aid society in “securing appropriate living arrangements” for 16- or 17-year-olds who need “out-of-home placements.” The fact sheet for service providers specifically states that when a youth enters a voluntary agreement, the CAS:
… will work with the youth to develop a plan and secure an appropriate living arrangement that will best meet the youth's needs and is informed by the youth's wishes, and is appropriate to the youth's development and readiness for independence.
47 The Fact Sheet for Young People includes similar statements and emphasizes that the children’s aid society will assist in ensuring the young person has “safe and appropriate” housing. For example:
If you are in need of protection, and you cannot be adequately protected at home or in your current living situation, and there are no safe options with family or friends, you may enter into an agreement with a [children’s aid] society for services and supports, including a housing option that is safe and appropriate. This is called a Voluntary Youth Services Agreement (VYSA).
48 While not legally binding, these fact sheets further illustrate how service providers are expected to interpret the requirements in the CYFSA and its regulations when serving 16- and 17-year-olds.
49 York CAS also has a Voluntary Youth Services Agreement policy, setting out how it will provide protection services to 16- and 17-year-olds. Consistent with the CYFSA and the Ministry’s policy directive, the York CAS policy states that 16- and 17-year-olds who are in need of protection are eligible for a Voluntary Youth Services Agreement and are entitled to the “full range of child protection services.” The policy notes that this may include “financial and other supports,” but does not provide further details.
50 Frontline staff at York CAS must determine that a youth meets the eligibility requirements for a VYSA and discuss that option with them, before the youth can access these supports. The worker must then obtain supervisory approval. If approval is granted and the youth agrees to participate in the VYSA program, the worker will contact the Office of the Children’s Lawyer to help them obtain independent legal advice. If the youth still wishes to proceed, the terms of the voluntary agreement will be agreed on between the youth and their worker. York CAS’s Finance Department must receive a copy of the voluntary services plan and any documentation needed for payments.
51 Once the agreement is in effect, the child protection worker or children’s services worker must visit the youth within seven days to assess their safety and wellbeing, and to begin the process of identifying their strengths, needs and goals.
52 VYSAs are relatively rare for York CAS. According to the data York CAS provided, it averaged around 12 per year between 2018 and 2022. Most of the youths who had these agreements received support to live independently, while others were placed with kin, in a shelter, or in a foster or group home.
York CAS VYSAs and placement decisions, 2018-2023
| Year |
# of VYSAs signed |
Accommodations: Internal Foster Care, OPR Foster, OPR Group |
|
|
Accommodations:Independent Living (IL), Kin, Shelter |
|
|
| |
|
Internal Foster Care |
OPR Foster |
OPR Group (360 Kids) |
IL |
Kin |
Shelter |
| 2018 |
11 |
|
|
|
9 |
|
2 |
| 2019 |
17 |
4 |
3 |
1 |
8 |
1 |
|
| 2020 |
16 |
1 |
1 |
|
11 |
1 |
2 |
| 2021 |
7 |
|
|
1 |
5 |
|
1 |
| 2022 |
11 |
1 |
2 |
1 |
5 |
2 |
|
| Totals |
62 |
6 |
6 |
3 |
38 |
4 |
|
53 In addition, York CAS had a specific policy in place at the time to address when children and youth should be placed in an external placement, or “Outside Paid Resource (OPR).” The policy said its purpose was to “outline the requirements of placing children and youth in family-based settings and to ensure accountability and oversight of their care when placed in an Outside Paid Resource.” York CAS defined OPRs as licensed “organizations that provide private foster care and/or group care.”
54 The policy required that children and youth who were admitted to the care of York CAS be placed in a family-based setting within the youth’s own extended family and community wherever possible. “Internal society homes,” which are associated directly with York CAS, and community treatment homes were considered next. It was only when all of these options had been exhausted that the CAS would begin to look for an external placement.
55 The policy did not address whether it applied to children who were not in care and who were instead receiving voluntary services without residential care. This is likely because the policy was not changed to reflect the new requirements in 2018 to provide voluntary services to 16- and 17-year-olds. One sentence suggested that the policy requirements only applied “upon admission to the care of the Society.” For youths receiving voluntary services, admission to the care of the Society only occurs if they are placed in a residential setting, such as a foster home. However, the rest of the policy spoke generally about placements for all children and youth, regardless of their status in or out of care. Those we spoke with believed the policy applied to Mia’s circumstances, even though she was never a child in care. They said the policy’s procedures were followed when assessing her eligibility for an external placement.
56 The policy set out a specific procedure that staff had to follow to request an out-of-home placement. If they determined that a child could not be kept safe in their own home, staff filled out a placement request form, and then the placement worker looked at internal resources, such as foster parents who worked directly with York CAS. If there were no internal resources available, the co-ordinator would seek approval from the Placement and Residential Development Supervisor to begin searching for an external placement with an outside paid resource. The Placement and Residential Services Supervisor then advised the Director of Service of the request.
57 If an appropriate external placement was found, staff completed a “Placement Search Form/OPR Approval Form,” and the placement co-ordinator would make a final recommendation to the Residential Development Supervisor setting out the rationale for the placement and the daily cost. The policy required that the Chief Operating Officer approve all placements in “group care” provided by outside paid resources, although it did not define this term. Those we spoke with and the emails we reviewed confirmed that, in practice, all external placements required approval from the Chief Operating Officer at the time Mia was receiving services.
58 However, the former Chief Operating Officer told us that only decisions about placements in group homes needed his approval, and that placements in other types of outside paid resources, such as foster homes, were a joint decision between the Residential Services Supervisor and the Director of Service. He also said he wanted some of these decisions to come to him directly because when placement decisions were made at the supervisor level, “way too many kids” ended up being in the care of outside paid resources.
59 While it is sometimes necessary to bring children into care to keep them safe, children’s aid societies have increasingly focused on early interventions that can help reduce risk and avoid this outcome. These strategies are generally referred to as “admission prevention” and were introduced in the 2016 Ontario Permanency Funding Policy Guidelines issued by the Ministry.[17] These guidelines apply to children in care, as well as those returning home or at risk of coming into care, and indicate that CASs should ensure a child is safe using the least disruptive manner possible – for instance, by providing supports for the family or facilitating kin and community placements. During our investigation, we repeatedly heard that a sector-wide focus on “admission prevention” influenced how York CAS delivered services to Mia.
60 In some cases, children’s aid societies may be able to provide financial assistance to address factors that put children at risk. They can also work with and connect families and children to existing government benefit programs, family members, and community programs. These approaches can eliminate the protection concern that puts the child at risk and prevent them from being taken into care. In explaining the rationale for admission prevention and the possibility of financial support to families, the Ministry guidelines note:
…early intervention to reduce urgent risk situations can better position parents to address the issues causing their child to be in need of protection and ultimately enable children to remain out of care on that occasion as well as possibly in future.[18]
61 However, the Ministry guidelines are clear that the principles of admission prevention should never leave a child unsafe, and if other strategies do not resolve a safety concern, more intensive interventions may be necessary.
62 At the time of Mia’s interactions with York CAS, it was in the midst of rolling out and implementing its first admission prevention strategy. The details were set out in a January 2019 document called “Keeping Children with Family: Admission Prevention Guidelines.”
63 In this document, York CAS defines admission prevention as “service planning and interventions that support the child(ren)/youth remaining with their primary caregiver(s)” and notes that “these intervention strategies are specifically targeted to prevent the child(ren)/youth from being placed in the Society’s care.” The guidelines make it clear that York CAS views admission prevention as the preferable and least intrusive method of intervention, and that it only applies to children who may come into care.
64 Staff at York CAS told us that the intention was to offer children in need of protection the same level of financial and staff support that a child in a foster or group home would receive so they can remain with their family, extended family, or in a customary care arrangement. Although youths receiving voluntary services are generally not considered children in care, this same principle applies, as these 16- and 17-year-olds are entitled to the full range of protection services offered to younger children.
65 York CAS’s Admission Prevention Guidelines set out a 10-point strategy to financially and logistically support families so that their children can stay at home. Of these 10 points, a few are especially relevant to Mia’s experience. For instance, the guidelines require that a child or youth’s well-being should always be the primary consideration. Extended family, kin or customary care should be the primary alternative care option, and staff must document efforts made to pursue kin or customary care arrangements for children prior to placing the child outside their home. If it is determined that a young person requires residential or group care, there must be an “Admission Prevention Planning Conference” that includes the assigned intake worker and their supervisor, the placement supervisor, the Diversity/Outreach Supervisor and Service Supervisor, as well as legal counsel and staff responsible for locating and contacting members of the child’s extended family or community. Others may also be included, depending on the needs of the child and the family.
66 Most of the York CAS staff we interviewed considered the agency’s focus on admission prevention to be a positive initiative, although there were some concerns about the specific approach taken by senior management. One person noted that there was no clear plan for reducing admissions, and that senior management used what they characterized as a “punitive” and “fear-based” culture to pressure child protection workers not to take children into care or offer placements to youths receiving voluntary services. These comments are not inconsistent with a report issued by the Ministry in October 2020, which set out several observations on the working culture at York CAS. We also were told that senior management at York CAS spoke openly about “competing” with another children’s aid society to see which could bring the fewest number of children into care.
67 When we asked the former Chief Operating Officer about the initiative and these types of comments, he told us he was heavily involved in admission prevention, even prior to his work at York CAS. He said that when he arrived at York CAS, the initiative hadn’t gained much traction, but he quickly set a goal of returning five children to their families or communities. Once the initiative was in full swing, he said that when cases were brought to him for review, he made certain all options for family and other supports were considered prior to putting a child in a foster home or other placements. He noted how important it was to make the right decision, as removing a child from their home is often traumatizing. However, he acknowledged that if family supports weren’t meeting the needs of the child, York CAS would “look at” other placement options.
68 Mia was born in 2003 to a family that lived in the Greater Toronto Area. Her family was involved with local children’s aid societies at numerous points throughout her life.
69 Between 2004 and 2017, Mia’s family was the subject of 15 separate investigations conducted by the Children’s Aid Society of Toronto (CAST). These investigations largely stemmed from reports made by teachers, police officers, the Office of the Children’s Lawyer, and others who were concerned about the care that Mia and her siblings received at home. These investigations verified incidents of inappropriate physical discipline and/or emotional harm by Mia’s maternal grandmother, maternal uncle, mother and father. Many other family members in Mia’s life were also the subject of unverified allegations relating to her and her siblings. As a result of these concerns and others, Mia’s older sister was taken into extended society care by CAST in 2015.
70 As Mia was growing up, her parents were involved in a difficult custody dispute that lasted many years. Ultimately, the court ordered that Mia would live with her father. However, Mia struggled with this living arrangement, and in 2016 she disclosed to the Children’s Aid Society of Toronto that she was afraid to return to her father’s home because he physically abused her, her siblings, and had previously abused her mother. Mia’s mother subsequently allowed her to stay with her, but the court order granting custody to the father remained unchanged. Around this time, CAST provided child protection services to Mia and her family, but eventually closed its file as there were no imminent protection concerns while Mia was in her mother’s care.
71 On September 23, 2019, York Regional Police contacted York CAS after an incident between Mia and her mother. By this point, Mia was 16. The police told York CAS that Mia’s mother called them after she and Mia argued and she forced her daughter to leave home. According to Mia and her siblings, the argument erupted when Mia allowed her half-brother to use her health insurance coverage for an eye exam. The mother became angry when she learned that she would now have to pay for Mia’s eye test. Mia said her mother “flipped out” and “kicked” her out. In speaking with the police, Mia’s mother said she was concerned because Mia left saying that she wanted to die. She told police Mia was staying with her maternal grandmother.
72 Based on the police report, York CAS opened an investigation on September 24 into whether Mia was in need of protection, and initially assessed the referral as potential child abandonment and caregiver-child conflict. This required a seven-day response time, which meant that staff, in accordance with Ontario Child Protection Standards, were supposed to speak with Mia in person within seven days. York CAS determined the risk was “high” for Mia and her family, as there were previous allegations against Mia’s father and the family had received ongoing services from the Children’s Aid Society of Toronto.
73 A York CAS intake worker tried to call Mia on September 26, but didn’t get through and had to leave a message. When she tried again on September 30, Mia’s cell phone was out of service. That same day, the worker tried to meet with Mia in person at her grandmother’s house, but this attempt was also unsuccessful. The supervision notes on file indicate that the worker received approval for a departure from the standard that she meet with Mia within the required seven-day time frame.
74 The worker tried to meet with Mia at school on October 4. Mia was not there, because she was not able to get there from her grandmother’s house.
75 On October 7, Mia’s father called York CAS to share concerns about Mia living with her grandmother. He felt that Mia’s sister, who also lived with the grandmother, was a bad influence because she drank and did drugs. He asked that York CAS consider placing her in foster care.
76 The intake worker connected with Mia for the first time on October 8. During that and subsequent conversations, Mia confirmed that she had an argument with her mother and they weren’t speaking to each other, that she was living with her grandmother, and that she was trying to get back into school. She said she was having trouble registering at a new school near her grandmother’s home because her mother would not give her the necessary paperwork. The notes on the file indicate that Mia’s long-term plan was to remain with her grandmother. The intake worker called Mia’s mother twice after this conversation, but only reached her voicemail.
77 The intake worker arranged to meet with Mia again on October 10, but Mia did not show up. She also did not answer a call on October 17. The worker met with Mia’s younger siblings at their school, and based on those interviews, the siblings were determined to be safe and not in need of protection.
78 On November 7, Mia’s mother called York CAS with concerns that no one knew where Mia was. On November 8, a second referral was made to York CAS by a community worker who had communicated with Mia in the past. According to the worker, Mia had told them that her sister demanded she leave their grandmother’s house. Mia had also disclosed that her stepfather sexually abused her when she was 13. These additional allegations and protection concerns were added to the York CAS file for investigation.
79 Also on November 8, the intake worker spoke with Mia and learned she was now living with her aunt, but that she would have to leave the next day. Mia said she had no other friends or family she could stay with, and she requested a foster placement.
80 The intake worker called shelters in search of a bed that she could refer Mia to, but was unsuccessful. The worker also suggested Mia go to her father’s or mother’s house, but Mia refused both options because she felt unsafe with her parents.
81 The intake worker then asked Mia’s aunt if she would allow Mia to extend her stay with her. The aunt reluctantly agreed, but explained that the situation was tense and untenable for the long-term.
82 As these events were unfolding, the intake worker began investigating the new sexual abuse allegations that Mia had made against her stepfather. On November 11, Mia met with York Region Police and the worker observed the interview. On November 12, the police interviewed Mia’s mom and two younger sisters.
83 On November 13, the intake worker spoke with Mia’s aunt again and advised her that once she left her house, Mia’s only available options would be a bed in a shelter or living on the streets. After this conversation, her aunt agreed to let Mia stay with her until the end of November. This was only a temporary solution, because there was limited space in the aunt’s home, and interpersonal conflict between Mia, her aunt, and others in the house. During this period of uncertainty, Mia remained out of school because she still did not have the documents she needed to register for a new school.
84 On November 20, the intake worker spoke with Mia about the possibility of entering into a Voluntary Youth Services Agreement. The worker connected Mia with a lawyer at the Office of the Children’s Lawyer, and Mia met with the lawyer on November 26 to discuss the expectations and responsibilities related to an agreement.
85 The case notes indicate that the intake worker continued to explore options that would allow Mia to live with a family member or friend. On November 20, the aunt again told her Mia could not live with her beyond November 30. The aunt also said the grandmother would not take Mia, and that she couldn’t think of any other family for Mia to stay with. The intake worker spoke with Mia’s father to explore other family options on November 21, but he did not have any ideas.
86 On November 21, having determined that it was unlikely that Mia could safely stay with anyone in her extended family or community, the intake worker contacted York CAS’s Placement Department to begin the process of finding her a foster home.
87 While the placement worker searched for a foster home, the Placement Department encouraged the intake worker to continue exploring options with Mia’s family and friends. According to the case notes, the placement worker also told the intake worker to emphasize to Mia “the reality of foster care, i.e./won’t be in the community she wants, living with people she doesn’t know, more rules, etc.”
88 According to those we spoke with, the placement worker’s search did not uncover any “internal” York CAS foster homes that would meet Mia’s needs. However, three external foster homes operated by “outside paid resources” were available and appropriate for Mia.
89 On November 28, the placement worker shared this information with a supervisor, and the supervisor brought these options to the Director of Service for approval.
90 After some back-and-forth, senior management at York CAS denied the request to place Mia in an external foster home. An email from the placement supervisor documenting this decision provided this explanation and next steps (emphasis added, and names redacted):
I am covering placement today and as there are currently no internal [placement] options available, I spoke with [the Director of Service] for Director’s approval to seek an OPR foster placement.
This was not approved, as it was felt that as per our agency's admission prevention strategy and not placing children and youth in OPRs, there are still family options that must be more deeply explored, that the youth is 16 and while she could come in on a VYSA, she can also stay in a shelter.
[The Director of Service] advised that if you did not agree with this decision, that [the Intake Supervisor] would need to take this to [the Director of Intake Services], who would then need to talk with [the Director of Service] and [the Chief Operating Officer].
91 The Intake Supervisor responded to this email almost immediately to explain that all family options had already been explored and that Mia’s mother did not want to be in contact with her. He reiterated that Mia’s living situation was precarious and that she would be homeless within a day or two. He also explained that Mia had already met with the Office of the Children’s Lawyer and consented to a Voluntary Youth Services Agreement. The Intake Supervisor underlined the seriousness of Mia’s living situation, explaining that “if admission is denied, then a shelter is this 16-year-old’s only option, if we can find an available spot, which is a challenge, otherwise she has no other option.” He added that the long-term plan was family reintegration with Mia’s father, but that the plan was at a “very early stage” and the father was not yet willing to care for her.
92 Within the hour, the intake worker began contacting shelters on Mia’s behalf. The worker spoke with Mia to explain that the only potential option York CAS could offer was a bed in a shelter, that Mia would need to call the shelters herself, and that it would be a good idea to reach out to all possible friends and family to find a place to stay.
93 The same day, the intake worker told the Children’s Lawyer counsel who was working with Mia that York CAS would not be providing Mia with a place to live, and that they were trying to connect her with a shelter. According to the worker’s notes from the call, the counsel said she did not feel that the VYSA process was keeping Mia safe, and that she would be contacting York CAS’s legal department.
94 Mia’s housing situation remained in limbo after she left her aunt’s house on November 29. On December 6, she told her intake worker she was temporarily staying with her grandmother again. She said her grandmother agreed to take her in the short term, as she did not want Mia on the streets or in a shelter.
95 On December 9, counsel from the Office of the Children’s Lawyer contacted York CAS’s Chief Operations Officer with concerns about the services being offered to Mia. Their emails reiterated that it was “not tenable” for Mia to remain at her grandmother’s and that she wanted a placement in a foster home. The lawyer described the use of youth shelters as a “systemic issue” and stated the Office’s position that clients should have a right to decline shelter-type options and instead receive care placements.
96 On December 10, Mia’s intake worker followed up internally to see if management had agreed to enter into a Voluntary Youth Services Agreement with Mia. The worker said Mia didn’t feel ready to pursue independent living, after just turning 16. She reiterated that Mia’s family was not committed to providing Mia a stable place to live, and that this had been the case since September. After some discussion with the worker about the short-term plan for Mia, the supervisor consulted with the Director of Service and obtained approval to finalize her VYSA.
97 On December 11, 2019, Mia signed a Voluntary Youth Services Agreement with York CAS. Under the CYFSA and the Ministry’s voluntary youth services policy, this meant that she was entitled to the full range of protection services available to younger children. The agreement noted that she “wanted support from the Society to assist with stability and to re-enroll in school.” By that point, Mia had been out of school for almost three months, ever since she was forced to leave her mother’s home. Before signing the VYSA, Mia agreed to all the rules and expectations associated with receiving support through such an agreement. She told her intake worker she would go “anywhere” to live in a foster home and was only with her grandmother temporarily to avoid staying in a shelter.
98 On December 12, the York Region Police concluded their criminal investigation into the allegations against Mia’s stepfather and decided not to lay any charges.
99 Also on December 12, a lawyer at the Office of the Children’s Lawyer again emailed the York CAS Chief Operations Officer to raise concerns about several youths who were receiving voluntary services through the CAS. The lawyer noted, “they are being told that there are no placement spots for youth and that [outside paid resources] are not available to them, with shelters being the default.” The lawyer also observed that this was “creating problems,” and that young people receiving voluntary services should have access to the same services, supports and resources as those in interim or extended CAS care. This attempt to raise awareness of the situation did not influence the placement options offered to Mia.
100 Mia’s worker called her on December 16 to schedule a visit for the following day. Mia did not show up for the meeting. On December 18, the worker obtained supervisor approval for a departure from the requirement that staff meet with the youth within seven days of signing a voluntary services agreement.
101 On December 18, York CAS concluded its investigation into the child protection concerns related to Mia. The following verification decisions were made with respect to each allegation:
42 C (Abandonment by a caregiver; caregiver-child conflict)
Verified: Mia was “kicked out” of her mother’s home due to an argument with her mother. The worker verified that Mia’s mother was not planning for Mia to return to the home due to ongoing conflict.
42 A (Abandonment by a caregiver; caregiver-child conflict; imminent risk of separation/physical assaults)
Verified: Mia signed a voluntary agreement as she did not want to return to her mother’s care due to alleged sexual abuse by her stepfather.
13 A (Physical/sexual harm; abusive sexual activity; sexual abuse-primary caregiver)
Not Verified: Peel Regional Police did not press charges against Mia’s step-father. The police advised that Mia’s explanation of the events was not credible. Mia’s mother denied that she was made aware of the allegations, and no disclosures were made by Mia’s younger siblings.
51 C (Caregiver capacity; history of abuse/neglecting; previous/current child exploitation)
Not Verified: No disclosures were made by Mia’s younger siblings to verify physical or sexual abuse in the home. No charges were laid against the stepfather.
102 Another week passed with Mia living at her grandmother’s house, a situation that Mia described as chaotic, unstable, and “not ideal.” On December 24, staff at York CAS circulated emails about Mia’s ongoing desire for a foster care placement and her willingness to live “anywhere.” These emails reiterated that Mia was not approved for an external or “OPR” placement, and that she would be considered for an appropriate internal foster home placement if one became available. However, staff acknowledged that there were few options available internally for a child of Mia’s age.
103 On December 27, York CAS staff arranged to meet with Mia on January 2, 2020. However, the meeting didn’t happen, because Mia didn’t answer the door at her grandmother’s house. Mia called her worker later on January 2 and said she hadn’t heard the knock and that her cellphone had no service. The visit was rescheduled.
104 On January 3, York CAS staff considered the unsuccessful visit with Mia and the ongoing issues with finding an internal foster care placement. Staff discussed that multiple placements with outside paid resources remained available and suitable for Mia, but that they were not approved by senior management.
105 Some time later, Mia died suddenly. Her grandmother and aunt were with her at the hospital when she passed away. To protect Mia’s identity and her family’s privacy, this report omits further details about her death.
106 As required, because she had received services from them both in the last 12 months, York CAS and the Children’s Aid Society of Toronto submitted Death and Serious Bodily Harm reports to my Office, outlining the circumstances of Mia’s death.
107 Mia’s death was also reported to the Office of the Chief Coroner.[19] The Regional Coroner reviewed these reports and determined that there was not an immediate connection between Mia’s death and the services provided by York CAS. The Coroner did not investigate further.
108 In the wake of the Coroner’s review, my Office received a complaint in May 2020 that raised serious concerns about the adequacy of services provided by York CAS prior to Mia’s death. In response, we began gathering information about Mia’s interactions with York CAS from October 2019 to January 2020.
109 As our review was commencing, the Ministry of Children, Community and Social Services launched its own operational review of York CAS, after receiving troubling allegations of racism, bullying, and harassment involving senior management.
110 While not directly related to the circumstances surrounding Mia’s death, the Ministry’s October 2020 report on this review outlined serious issues with the working culture at York CAS, describing it as “an autocratic, deficit-based culture of fear that targeted dissent and enabled oppressive behaviours.”[20] The Ministry concluded that York CAS was meeting Ministry and legislative requirements, but that staff morale was “extremely low” and workplace issues were affecting service delivery, specifically with respect to decision-making and compliance.
111 The Ministry’s report also found that York CAS treated racialized families and children differently from non-racialized families, and that there was little training or focus on racism and anti-black racism.
112 Frontline staff, supervisors and even directors told the reviewer they were not trusted to make care-related decisions for children and their families. They said many decisions were made at the senior executive level, sometimes resulting in poor quality decisions and service delivery. “A senior leader in the organization is often responsible for making the final decisions about out-of-home placements without considering caseworker assessments or children’s wishes,” one was quoted as saying. Another staff person said some decisions, especially those related to admission prevention, were “financially driven” and that there were “hard quotas to return children home at all costs.” This person felt that “safety concerns were ignored or minimized, which put children at risk.”
113 The Ministry recommended that York CAS review its internal decision-making processes, as well as the roles and responsibilities of staff at different levels of the organization. It indicated that the goal of this recommendation was to address concerns related to how decisions were made to bring children into care or return them to their families.
114 York CAS developed a work plan to address these recommendations, with an overall goal of strengthening services for children and families.[21] As of September 2023, there had been significant turnover in senior leadership and York CAS reported that around 90% of the recommendations had been fulfilled, with the remaining recommendations on schedule for completion.
115 Separate from the review conducted by the Ministry, York CAS hired an external reviewer to conduct an Internal Child Death Review, focused on Mia’s interactions with York CAS. Completed in May 2022, the report was based on information provided by York CAS and its staff and determined that the CAS was in “substantial compliance” with applicable legislation, standards, policies, and procedures. It noted that staff were committed to help Mia through a Voluntary Youth Services Agreement, but there were “issues” related to placement supports for youths receiving voluntary supports.
116 The review determined that there was a lack of clarity within York CAS about whether children receiving services through a VYSA are “children in care” under the CYFSA. This is likely because most youths who receive voluntary services are not in care, while a small subset who receive residential care at a foster or group home are. This confusion may have affected decision-making around whether to offer Mia an external placement, given York CAS’s significant focus on reducing the use of these placements for children in care. The external reviewer’s report reiterated the Ministry’s finding that staff had specific targets or “quotas” for reducing the number of children in care.
117 Lastly, the report found that York CAS should have arranged a family meeting or case conference that included Mia, her parents, aunt and grandmother to focus on solutions and problem-solving regarding Mia’s living situation. Such a conference might have also helped in exploring sources of support in Mia’s broader community.
118 In addition to these specific findings, the report made general comments about various structures at York CAS, including the decision-making hierarchy. It found that decisions regarding approvals of external placements with outside paid resources were made at the Chief Operations Officer level and communicated to a director who, in turn, communicated the decision to a supervisor.
119 The report made four recommendations, including that York CAS should review placement decision processes for young people under VYSAs and ensure that the needs and circumstances of each youth are assessed. York CAS was asked by the reviewer to forward copies of this report to the Chair of the Paediatric Death Review Committee, my Office, and the Ministry’s regional office.
120 At the time of her death, Mia was bouncing between precarious living arrangements, unable to attend school, and willing to live anywhere that would provide a more stable home. While York CAS staff described Mia as “brave,” she was clear that she was not ready to live on her own after just turning 16. She told her worker several times that she wanted the chance to continue high school. Tragically, Mia did not have this opportunity.
121 There is no obvious connection between the services that York CAS provided to Mia and her death. However, her experience in trying to access protection services shines a light on significant issues in how York CAS approached Voluntary Youth Services Agreements. Most importantly, it demonstrates the importance of respecting the rights and listening to the voices of children who are meant to be protected under the Child, Youth and Family Services Act, 2017.
122 The Child, Youth and Family Services Act, 2017 provides children receiving services under the Act with certain rights, including the right to have input into decisions made about their placements. Specifically, section 3 of the Act provides that children receiving services have the right:
2. To be engaged through an honest and respectful dialogue about how and why decisions affecting them are made and to have their views given due weight, in accordance with their age and maturity; [and]
3. To be consulted on the nature of the services provided or to be provided to them, to participate in decisions about the services provided or to be provided to them.
123 Regulations under the Act provide additional guidance on how to operationalize these rights. For instance, service providers, such as children’s aid societies, must document how and when they gave the child an opportunity to participate in decision-making that affected them. The service provider must also document whether the child participated, and if so, provide a description of how they participated and any views they expressed.[22]
124 Mia was found to be a child in need of protection, and York CAS offered her voluntary services through agreement. After running out of options to live with her extended family, Mia consistently stated that she wished to live in a foster home and was willing to live anywhere that was offered. She said she did not feel safe living with her mother or father, and that other family members were not willing to let her stay with them any longer. Mia’s mother, father, grandmother, and aunt all said that they could not think of any family or community member that could take her into their home long-term. Her mother and father both agreed that Mia needed a foster home and supported York CAS’s involvement.
125 The Office of the Children’s Lawyer attempted to advocate for Mia, highlighting that she should not remain at her grandmother’s, and that she wanted a placement in a foster home. Her lawyer reiterated that young people should have a right to decline shelter-type options and instead receive care placements.
126 Frontline staff and supervisors at York CAS were well aware of Mia’s goal of finding a foster home and re-enrolling in school. These wishes were repeatedly documented and taken into account by the intake worker, placement co-ordinator, and relevant supervisors. They were also documented in her Voluntary Youth Services Agreement. Our investigation found ample evidence that staff diligently looked for appropriate foster placements for Mia within York CAS and externally.
127 Staff were unable to find an appropriate foster home within York CAS, but identified three external foster homes with openings that would be a good fit. These efforts were timely and centred on Mia’s protection needs and her expressed wishes. However, when staff sought internal approval to proceed with the foster home placement they found, York CAS senior management denied the request, saying there were “family options that must be more deeply explored” and Mia could just “stay in a shelter.” There is no indication that Mia’s views were given due weight, in light of her age, maturity, and stated goal of completing her education, when the decision was made to further explore family options and send her to a shelter in the meantime.
128 Most of the staff we spoke with at York CAS said it was the former Chief Operations Officer who decided that Mia would not be placed at an external foster home. But in his interview with our investigators, he denied having any knowledge of Mia’s circumstances or involvement in this decision. When her situation was explained, he told us:
[T]his child's wishes should have been centre in the decision-making. If the child said, "I don't want to be placed with family," there needed to be an exploration of that … and that needs to be factored into what the service plan, you know, certainly looks like.
129 The former Chief Operations Officer said that from his perspective, “there would be no reason why a … foster home wouldn't be approved if that is what the child is asking for and if that is what the assessment kind of speaks to … it's based on what the child's wishes are as well.”
130 However, our investigation found no evidence that Mia’s voice and wishes were considered at the final level of decision-making. Based on the records we reviewed and those we spoke with, the primary reason provided for denying her foster home placement was related to York CAS’s ongoing admission prevention initiative. Ultimately, Mia and her extended family were forced to choose between having her live on the streets, a shelter if space was available, or in a precarious housing situation where she was not wanted, could not live long-term, and did not meet her goal of attending school. Throughout, Mia said she wanted the stability that a foster home would provide – but no one with decision-making power would listen.
131 Young people receiving services under VYSAs have the legal right to be heard and to have their perspectives considered. The law requires that their views be given due weight, in accordance with their age and maturity. In a different context, the Child and Family Services Review Board has generally observed that the right to be heard requires active listening, discussions, taking steps to address a person's concerns, and communicating this to them in a way that ensures they feel their concerns have been taken seriously and dealt with thoroughly.[23] A CAS is entitled to make the final decision, but the outcome should be informed by and grapple with the stated wishes of the youth.
132 To ensure that the voice of a youth requesting or receiving voluntary services is heard, York CAS must note the youth’s requests and adequately consider them in the decision-making process. As part of this process, staff should be required to meet with the youth to seek their input on the proposed decision, and document the youth’s views in writing. The youth should be provided with a copy of this document and given the opportunity to provide additional information that they wish to be taken into consideration before a final decision is made.
133 York CAS must also provide young people in this situation with clear information about why decisions affecting them are made, and how the decisions incorporate and give due weight to their voices. York CAS should ensure it discusses such decisions and the supporting rationale directly with the affected youth. To promote accountability, transparency, and high quality decision-making, York CAS should also provide this information to the youth in writing so that they have a record and can share it with other sources of support, such as social workers, my Office’s Children and Youth Unit, or the Office of the Children’s Lawyer.
Recommendation 1
York Region Children’s Aid Society should ensure that the voice of any youth requesting or receiving voluntary services is heard, by requiring that staff meet with them to seek their views on proposed decisions affecting them, document the youth’s views in writing, share this document with them, and give them an opportunity to provide additional information before making any final decision affecting them.
Recommendation 2
York Region Children’s Aid Society should provide any youth requesting or receiving voluntary services with an oral and written explanation of why significant decisions affecting them were made, including details of how the decision incorporated their voice and gave it due weight, in accordance with their age and maturity.
134 Further, staff at all levels must ensure that the youth’s best interests are central to their decision-making about their situation. Our investigation found no evidence that senior staff considered what was in Mia’s best interests when they denied her external foster home placement. All staff at York CAS should ensure that the best interest of the youth guides their service provision. To assist staff in making these decisions, York CAS should provide all staff who make decisions affecting youths requesting or receiving voluntary services with training on how to make decisions that are in the best interests of the young people and incorporate their voices, giving them due weight in accordance with their age and maturity. York CAS should also consider establishing a “placement conference” model for youths requesting or receiving voluntary services that potentially include placement in foster or group care. This would bring together the young person, anyone they determine to be important, and decision-makers at all levels within the CAS, and help ensure that the youth’s voice and best interests are centred in the placement decision. This model would be consistent with the Ministry’s Quality Standards Framework, which recommends that CASs use a multi-disciplinary team approach when placing youths in residential care settings.[24]
135 In addition, York CAS should establish and implement a permanent process for auditing the services provided to youths who requested or were offered voluntary services. The audit should assess whether staff complied with all applicable legislation and society policies, and ensure that each youth’s voice and best interests were paramount in the decision-making process.
Recommendation 3
York Region Children’s Aid Society should ensure that all staff are guided by a youth’s best interests and incorporate their voice, giving it due weight in accordance with the youth’s age and maturity, when making decisions that affect any youth requesting or receiving services under Voluntary Youth Services Agreements.
Recommendation 4
York Region Children’s Aid Society should provide all staff who make decisions affecting any youth requesting or receiving voluntary services with training on how to make decisions that are in the youth’s best interests and incorporate their voice, giving it due weight in accordance with the youth’s age and maturity.
Recommendation 5
York Region Children’s Aid Society should consider establishing a multi-disciplinary placement conference model for any youth requesting or receiving voluntary services that include possible placement in foster or group care. This model would bring together the affected youth, anyone they determine to be important, and decision-makers at all levels within the Society, and help ensure that the youth’s voice and best interests are centred in decisions about their placement.
Recommendation 6
York Region Children’s Aid Society should establish and implement a permanent process for auditing the services provided to youths who requested or received voluntary services. The audit should assess whether staff complied with all applicable legislation and Society policies, including the Child Protection Standards, and ensure that the youths’ voices and best interests were paramount in the decision-making process.
136 There is significant evidence that York CAS’s admission prevention initiative affected the placement options that were offered to Mia, even though she independently identified that she wished to come into care and live in a foster home. The email denying Mia’s external foster home placement noted that this decision was made “as per our agency's admission prevention strategy and not placing children and youth in [external placements].” While supporting children to stay in their homes and community is generally in their best interests and consistent with the CYFSA, all available information indicated that family reunification was not possible for Mia when she was denied access to an external placement.
137 The Admission Prevention Guidelines that were supposed to guide York CAS’s decision-making clearly state that a child’s well-being must always be the primary consideration. The Ministry’s Ontario Permanency Funding Policy Guidelines contain the same requirement. However, staff at York CAS told us they were under immense pressure to meet “quotas” and “very specific targets” as part of this initiative, regardless of what a child’s best interests were.
138 York CAS relied on “admission prevention” as the rationale for denying Mia her foster care placement request, despite significant documentation that she would end up on the streets or in a shelter. Senior management at York CAS told her intake worker to further explore family options, even though they had been thoroughly canvassed already.
139 Significant decisions affecting children’s lives should not be reduced to quotas and targets. York CAS must ensure that the best interests and needs of each child take precedence over any other agency strategies or initiatives.
140 In addition, York CAS should review its Voluntary Youth Services Agreement policy. The policy should be revised to set out clear criteria and procedures to guide decisions about placements and other supports offered to young people receiving voluntary services. The policy should emphasise that a youth’s best interests and needs are paramount in decision-making and reference the importance of giving appropriate weight to their views in accordance with their age and maturity. In addition, it should set out whether and how other policies at York CAS should apply to youths receiving voluntary services.
Recommendation 7
York Region Children’s Aid Society should ensure that the best interests and needs of children and youth take precedence over any other agency strategies, including the admission prevention initiative.
Recommendation 8
York Region Children’s Aid Society should review and revise its policy regarding Voluntary Youth Service Agreements to clearly set out:
- The criteria and procedures that guide decisions about placements and other supports offered to any youth receiving voluntary services;
- That the best interests and needs of the youth are paramount considerations in all decision-making;
- The importance of giving appropriate weight to the views of the youth in accordance with their age and maturity; and
- Whether and how other policies, such as those regarding admission prevention and placements with external providers, should apply to any youth receiving voluntary services.
141 By November 2019, Mia appeared to have no family members who were able or willing to let her live with them. She either could not or did not feel safe living permanently with her mother, father, aunt, or grandmother. No other family or community options were put forward for her. The staff at York CAS who worked with her directly, as well as some of their supervisors, determined that Mia would benefit from a foster home placement. Mia wanted to live in a foster home with some stability to allow her to continue her education. Her lawyer supported this request, and both her mother and father agreed it was in her best interests. Nonetheless, Mia did not receive a placement and was instead directed toward shelters.
142 When senior management at York CAS decided that Mia would not receive approval for an external foster home placement, frontline staff were told they should “more deeply” explore family options or send Mia to a shelter. Since staff already knew there were no family options available for Mia, the only possibility left, which was supported by senior management at York CAS, was a shelter for unhoused youths.
143 The intake worker contacted numerous shelters to find a bed for Mia, despite feeling that this was not an appropriate alternative. As she explained during an interview with our Office, “I had tried to call shelters because that was actually a response that I got from… [senior] management…was that she should go to a shelter. That was their backup plan as to where she could go because they didn't want to offer her a placement.”
144 There is nothing in York CAS’s policies or procedures that indicates that a youth receiving voluntary services should be redirected to the shelter system. Children receiving voluntary services are entitled to the full range of protection services that would be offered to younger children. The only difference is that in some circumstances, these 16- and 17-year-olds have the choice of whether to accept these services. However, we heard from one staff person that in reality, the “unwritten policy” and “established practice” was that children receiving voluntary services were offered shelter placements and other supports, not external placements with “outside paid resources.” Put bluntly, he said: “We interpreted the policy as shelters and other supports, not [external placements].” The supervisor involved in the request for Mia told us the former Chief Operations Officer had said that York CAS had a rule to not offer external placements to youths receiving voluntary services.
145 Data we received from York CAS paints a more complex picture. In 2018, it did not offer placements (internal or external) related to any VYSAs. Two youths were accommodated in shelters. In 2019, eight received internal or external placements, while nine others were accommodated elsewhere. In 2020, two youths received placements from York CAS, while 14 lived elsewhere, including two who were accommodated in a shelter. It is also possible that some youths who would have been housed in shelters chose not to enter into voluntary agreements with York CAS. As one staff person told us, “sometimes when [youths] find out they have to go to a shelter as their option, they do not sign [a VYSA].”
146 Historical practice may have impacted staff and senior management’s decision-making during these years. Prior to January 2018, a 16-year-old who called a children’s aid society for protective services would be referred to places like the shelter system or Ontario Works (a locally administered financial, benefits, and employment assistance program), since teens of that age were not within the mandate of CASs. The situation changed in 2018 with the implementation of Voluntary Youth Services Agreements and the extension of protection services to 18-year-olds.
147 Mia’s counsel with the Office of the Children’s Lawyer told us the use of shelters for 16- and 17-year-olds was an “institutional issue” at York CAS at the time of Mia’s death. The lawyer also outlined the circumstances of other young people who were told they must live in shelters because no other options were available. While the data we obtained does not suggest this practice was widespread, there are certainly examples of children receiving voluntary services who were redirected to the shelter system. It is also possible that the number of youths referred to the shelter system is higher than the data indicates, as children like Mia may have chosen to stay in dangerous or suboptimal living conditions to avoid a shelter.
148 The practice of routinely referring youths who are eligible for voluntary services to the shelter system must end. Youth shelters should never be the only housing option considered for those in need of protection. The CYFSA provides that all children under the age of 18 are entitled to the full range of protection services, including residential placements, if their protection needs warrant it. The Ministry’s materials related to VYSAs state that children who enter into these agreements are entitled to “appropriate living arrangements” and “safe and appropriate” housing.
149 Some children may independently feel it is in their best interests to live in a youth shelter. Some organizations operate youth shelters that offer significant stability and access to other supports and resources, and staff at the Office of the Children’s Lawyer and York CAS gave us several examples in the Greater Toronto Area that provide positive environments. If a youth wishes to pursue this type of living arrangement, they should have the option to do so while receiving voluntary services. However, it should never be their only choice.
150 Nothing in the Act, its regulation, or the policies of the Ministry and York CAS suggest that youths receiving voluntary services should be treated differently from younger children in terms of placements, or that a shelter is ever “safe and appropriate” for a child. York CAS should revise its Voluntary Youth Services Agreement policy to provide that shelters should not be considered as a housing option, unless it is clear that the shelter provides significant stability and safety, would meet the youth’s needs for access to appropriate supports and resources, and they have independently expressed an interest in this living arrangement.
Recommendation 9
York Region Children’s Aid Society should revise its Youth Voluntary Services Agreement policy to state that shelters should not be considered as a housing option for youths requesting or receiving voluntary services unless the shelter would provide significant stability and safety and meet the youth’s needs for access to appropriate supports and resources, and the youth has independently expressed an interest in this living arrangement.
151 When correctly implemented, the principles of admission prevention call on children’s aid societies to resolve protection concerns for children by providing them and their family constellation with the same level of resources that the child would receive if they were in care. In some instances, providing these supports directly within the child’s existing family structure resolves the protection concern and means that more disruptive options, like placing them in a foster home, are no longer necessary. York CAS’s Admission Prevention Guidelines reiterate and operationalize these principles through a 10-point strategy to financially and logistically support families so that their children can stay at home.
152 Mia was entitled to the full range of child protection services, and the principles underlying admission prevention, such as supporting children within their families and communities where possible to avoid more disruptive options, should have been explored. York CAS took no concrete steps to support her extended family to allow her to remain with them. Some family members did agree to allow her to stay with them for short periods, but they cited reasons like crowded households and interpersonal conflict to explain why they could not offer her more stability.
153 It is possible that these family members would have been able to safely care for Mia with additional supports, such as counselling or financial resources to help offset additional expenses. These supports could have been part of the voluntary services offered to Mia by York CAS, but there is no record in the case notes to indicate that they were ever considered. York CAS should revise its VYSA policy to require that staff continually fully explore and consider options that would allow youths with such agreements to receive supports within their own family and community. The policy should require that staff document how these options were considered.
Recommendation 10
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement policy to require that staff continually fully explore and consider options that would allow youths with such agreements to receive supports within their own family and community.
Recommendation 11
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement policy to require that staff document how they considered and reached decisions about these options for youths requesting or receiving voluntary services.
154 In operationalizing this type of support for youths with VYSAs, staff at York CAS may wish to convene planning conferences once it is determined that a youth receiving voluntary services may require a residential placement. These conferences are required when a child is in care, and are meant to bring together relevant York CAS staff and possible sources of support to see if there are any unexplored options for supporting the child within their community, thus preventing their admission to residential care. A planning conference could serve the same purpose for young people receiving voluntary services. There is no indication that staff considered whether this type of conference would be useful in determining how best to provide voluntary services to Mia. York CAS should revise its Voluntary Youth Services Agreement policy to require that staff convene planning conferences in instances where youths receiving voluntary services may require residential or group care.
Recommendation 12
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement policy to require that staff convene planning conferences in instances where youths requesting or receiving voluntary services may require residential or group care.
155 Further, there is no evidence that staff sought to engage with Mia’s immediate or extended family in the planning for her Voluntary Youth Services Agreement. Case notes indicate that family reunification was the goal for her, but frontline staff did little to account for or plan for that within the agreement itself. This may have stemmed from a lack of familiarity in how and when to engage a youth’s family when there is significant family conflict and the youth feels it is in their best interests to live apart from their family. To ensure that staff are adequately prepared to support young people and families in these circumstances, York CAS should revise its VYSA policy to provide guidance on how and when staff should engage parents and other caregivers in a child’s life in the planning and implementation of such agreements.
Recommendation 13
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement (VYSA) policy to provide guidance on how and when staff should engage parents and other caregivers in the planning and implementation of VYSAs.
156 Our interviews with York CAS revealed that a complicated hierarchy of decision-makers was involved in the decision to deny the request for Mia’s external placement.
157 Several staff we spoke with described this multi-step process. First, the frontline intake worker and supervisor made the clinical decision that Mia required a placement outside of her family. These staff members then sent relevant documentation to the placement team, and the placement worker began searching for possible internal placements. As there were none available or appropriate, the worker had to seek approval from their supervisor to look for external foster and group homes. The Placement Supervisor had to seek approval from the Director of Service, who, in turn, had to obtain approval from the Chief Operations Officer. The decision of the Chief Operations Officer then flowed back down to the frontline staff.
158 By our count, six people – up to the Chief Operations Officer – were typically involved in such decisions. In Mia’s case, it was more, because some positions were temporarily covered by others during important points in the decision-making process. Although the former Chief Operations Officer disputes his involvement, all others we spoke with indicated that he had the final say in the decision to deny Mia’s placement. Many staff told us they had little or no autonomy to act in the best interests of children and youth and that they had limited influence over significant decisions that affected their care.
159 York CAS followed the guidelines’ convoluted decision-making process when denying Mia an external placement. Under that process, only the Chief Operations Officer could approve placements in external group care. The staff we spoke with, as well as the process followed when requesting approval for Mia’s potential foster placement, reflect that the Chief Operations Officer had to approve all placement in external foster homes and external group homes. For his part, the former Chief Operations Officer told us he only had to approve placements in external group homes, not external foster home placements such as those being considered for Mia.
160 While checks and balances are important, multi-level approval processes mean that the final decision-maker has little familiarity with the circumstances of the child at the centre of a decision. In Mia’s case, only the frontline intake worker had spoken directly with her and the family members involved in her life. The intake worker told us she was never certain who made the final decision to not offer Mia a foster placement, and that she felt “there [was] just no opportunity to speak to anybody to kind of give a bit more detail” about Mia’s circumstances. A supervisor involved in Mia’s case told us she spoke with the Director of Service, hoping they could raise concerns about the former Chief Operations Officer’s decision, but the Director was unable to address a decision made at that level. Meanwhile, the former Chief Operations Officer told us he was not consulted about Mia’s placement and would never have denied it.
161 The discrepancy in witness evidence about the decision to deny Mia a placement in an external foster home is concerning. York CAS should revise the Voluntary Youth Services Agreement policy to set out the details of the placement approval processes for youths receiving voluntary services. The policy should provide that staff who have firsthand knowledge of the youth and their specific circumstances are consulted at all levels of decision-making, and that decision-makers are appropriately briefed on the youth’s best interests, needs and views. The policy should also provide that the decision-making is thoroughly documented at all levels, including written reasons supporting how the best interests, needs and views of the youth were taken into consideration. Clearly setting out the society’s approval practices for youths receiving voluntary services will help ensure consistent and high quality decision-making.
Recommendation 14
York Region Children’s Aid Society should revise the Voluntary Youth Services Agreement policy to set out the details of the placement approval process for youths requesting or receiving voluntary services, including who has authority to make decisions at all stages of the process.
Recommendation 15
York Region Children’s Aid Society should revise the Voluntary Youth Services Agreement policy to require that staff who have firsthand knowledge of the youth and their specific circumstances are consulted at all stages of decision-making, and that decision-makers are briefed on the youth’s best interests, needs and views.
Recommendation 16
York Region Children’s Aid Society should revise the Voluntary Youth Services Agreement policy to require that all decision-making is thoroughly documented at all levels, including who made a decision, and written reasons supporting how the best interests, needs and views of the youth were taken into consideration.
162 The obstacles Mia faced when trying to obtain services from York CAS were in part due to staff’s lack of familiarity with how to administer voluntary services. Some we spoke with were confused about whether and when a youth receiving voluntary services was considered “in care” and what sorts of services and supports they might receive. York’s Voluntary Youth Services Agreement policy is not detailed, and provides limited guidance to staff in these areas. Rather, the policy focuses on the mechanics of how to enter into voluntary agreements with youths and how often staff must perform certain tasks while the agreements are ongoing.
163 This lack of guidance, combined with a general lack of familiarity with how children should receive voluntary supports, likely contributed to the determination that York CAS would not provide an external placement to Mia, and that she could instead “go to a shelter.” When decisions about Mia’s care were being made in late 2019, Voluntary Youth Services Agreements were still relatively new and rarely used. Some of the staff we spoke with specifically noted that they had received minimal training when VYSAs first came into effect. Some said it was easy to forget the details, because they were not used often.
164 The impact of this confusion could be significant. While the legislation and York CAS’s own policy are clear that 16- and 17-year-olds who enter into voluntary agreements are entitled to the full range of protection services, this did not occur for Mia. These teens in need of protection deserve service from staff who have expertise in Voluntary Youth Services Agreements.
165 York CAS should ensure that all frontline staff receive comprehensive training on when Voluntary Youth Services Agreements may be appropriate, as well as practical information on how to engage with youths, how to initiate these agreements, and what services they can cover. It should also ensure that all staff receive training on the revised VYSA policy. York CAS should use this report and the experience of Mia and her family as a tool within this training to demonstrate the impact and importance of service delivery in the context of VYSAs. York CAS should also ensure that frontline staff receive regular refresher training on these topics so that staff are always prepared to offer these protective services.
Recommendation 17
York Region Children’s Aid Society should provide all frontline staff with comprehensive training on the legislative and policy requirements for Voluntary Youth Services Agreements, as well as its revised VYSA policy. York CAS should ensure this training includes practical information on how to enter into these agreements and what services they cover.
Recommendation 18
York Region Children’s Aid Society should use this report and the experience of Mia and her family as a training tool to demonstrate the impact and importance of service delivery in the context of Voluntary Youth Services Agreements.
Recommendation 19
York Region Children’s Aid Society should provide frontline staff with regular refresher training regarding the legislative and policy requirements for Voluntary Youth Services Agreements.
166 Because her voice was never heard and her requests for services were not adequately met, Mia never had the chance to regain stability and achieve her goal of returning to high school. Although her death was not the fault of York Region Children’s Aid Society, it highlighted significant deficiencies in the steps that were taken to protect her.
167 York CAS received a referral from the York Regional Police Service after Mia left her mother’s house in crisis after an argument, stating she wanted to die. Her mother would not allow her to return home and she had limited places to go. Right away, York CAS knew the risk was “high” for Mia and tried to connect with her on many occasions as she bounced from place to place in October and November 2019. She couch-surfed with family members who were only willing to house her temporarily and did not attend school. No one was willing or able to offer her a more permanent place to live. During this period, frontline staff at York CAS tried to help Mia find a family member she could stay with on a longer-term basis, but there were no realistic options. By late November 2019, her intake worker contacted York CAS’s Placement Department in an attempt to find her a foster home.
168 York CAS could not find an internal placement for Mia, and instead of arranging an external foster home, senior management determined Mia could “stay in a shelter” if her family would not house her. Mia, her family, her counsel from the Office of the Children’s Lawyer, and her frontline caseworker all believed that it was in Mia’s best interests to be placed in a foster home. Instead, the worker was forced to call youth shelters in search of an opening.
169 York CAS entered into a Voluntary Youth Services Agreement with Mia on December 11, 2019. It stated that Mia “wanted support from the Society to assist with stability and to re-enroll in school,” but York CAS never offered her a place to live or other tangible support.
170 The best interests of a child are supposed to be the paramount consideration in all child protection decisions. To help achieve this aim, the Child, Youth and Family Services Act, 2017 gives children receiving child protection services the right to have their voices heard and to participate in decision-making that affects them. Senior management at York CAS decided not to approve an external foster placement for Mia, although by then it was clear that her other options were untenable. This decision was not in her best interests, and there is little indication that Mia had any genuine ability to participate or have her voice heard by those who made the final decision, given the decision-making process and hierarchy followed at the CAS.
171 Many of those we spoke with attributed this outcome to the admission prevention initiative in place at the time. The principles underlying the initiative put pressure on staff not to place youths outside of their home. Some staff were also confused about the details of Voluntary Youth Services Agreements and told us they had not received thorough guidance and training about how to engage families and offer these services. There was no material effort put into supporting Mia within her own extended family, and it is possible that with financial and counselling support, she could have stayed with her grandmother or aunt.
172 The services that Mia received from York CAS fell far short of the ideals set out in the CYFSA, Ministry policy, and York CAS’s own policies and guidelines. As a result, the services that York CAS provided to Mia and her family from October 2019 until her death in January 2020 were inadequate, and it is my opinion that York Region Children’s Aid Society’s conduct was unreasonable and wrong under s. 21(1)(a) and (d) of the Ombudsman Act.
173 I have made recommendations to enhance the services that York CAS offers to 16- and 17-year-olds who are in need of protection. I will monitor its response to ensure it takes action to address the issues documented in this report.
Recommendation 20
York Region Children’s Aid Society should report back to my Office in six months’ time on its progress in implementing my recommendations, and at six-month intervals thereafter until such time as I am satisfied that adequate steps have been taken to address them.
Recommendation 1
York Region Children’s Aid Society should ensure that the voice of any youth requesting or receiving voluntary services is heard, by requiring that staff meet with them to seek their views on proposed decisions affecting them, document the youth’s views in writing, share this document with them, and give them an opportunity to provide additional information before making any final decision affecting them.
Recommendation 2
York Region Children’s Aid Society should provide any youth requesting or receiving voluntary services with an oral and written explanation of why significant decisions affecting them were made, including details of how the decision incorporated their voice and gave it due weight, in accordance with their age and maturity.
Recommendation 3
York Region Children’s Aid Society should ensure that all staff are guided by a youth’s best interests and incorporate their voice, giving it due weight in accordance with the youth’s age and maturity, when making decisions that affect any youth requesting or receiving services under Voluntary Youth Services Agreements.
Recommendation 4
York Region Children’s Aid Society should provide all staff who make decisions affecting any youth requesting or receiving voluntary services with training on how to make decisions that are in the youth’s best interests and incorporate their voice, giving it due weight in accordance with the youth’s age and maturity.
Recommendation 5
York Region Children’s Aid Society should consider establishing a multi-disciplinary placement conference model for any youth requesting or receiving voluntary services that include possible placement in foster or group care. This model would bring together the affected youth, anyone they determine to be important, and decision-makers at all levels within the Society, and help ensure that the youth’s voice and best interests are centred in decisions about their placement.
Recommendation 6
York Region Children’s Aid Society should establish and implement a permanent process for auditing the services provided to youths who requested or received voluntary services. The audit should assess whether staff complied with all applicable legislation and Society policies, including the Child Protection Standards, and ensure that the youths’ voices and best interests were paramount in the decision-making process.
Recommendation 7
York Region Children’s Aid Society should ensure that the best interests and needs of children and youth take precedence over any other agency strategies, including the admission prevention initiative.
Recommendation 8
York Region Children’s Aid Society should review and revise its policy regarding Voluntary Youth Service Agreements to clearly set out:
- The criteria and procedures that guide decisions about placements and other supports offered to any youth receiving voluntary services;
- That the best interests and needs of the youth are paramount considerations in all decision-making;
- The importance of giving appropriate weight to the views of the youth in accordance with their age and maturity; and
- Whether and how other policies, such as those regarding admission prevention and placements with external providers, should apply to any youth receiving voluntary services.
Recommendation 9
York Region Children’s Aid Society should revise its Youth Voluntary Services Agreement policy to state that shelters should not be considered as a housing option for youths requesting or receiving voluntary services unless the shelter would provide significant stability and safety and meet the youth’s needs for access to appropriate supports and resources, and the youth has independently expressed an interest in this living arrangement.
Recommendation 10
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement policy to require that staff continually fully explore and consider options that would allow youths with such agreements to receive supports within their own family and community.
Recommendation 11
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement policy to require that staff document how they considered and reached decisions about these options for youths requesting or receiving voluntary services.
Recommendation 12
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement policy to require that staff convene planning conferences in instances where youths requesting or receiving voluntary services may require residential or group care.
Recommendation 13
York Region Children’s Aid Society should revise its Voluntary Youth Services Agreement (VYSA) policy to provide guidance on how and when staff should engage parents and other caregivers in the planning and implementation of VYSAs.
Recommendation 14
York Region Children’s Aid Society should revise the Voluntary Youth Services Agreement policy to set out the details of the placement approval process for youths requesting or receiving voluntary services, including who has authority to make decisions at all stages of the process.
Recommendation 15
York Region Children’s Aid Society should revise the Voluntary Youth Services Agreement policy to require that staff who have firsthand knowledge of the youth and their specific circumstances are consulted at all stages of decision-making, and that decision-makers are briefed on the youth’s best interests, needs and views.
Recommendation 16
York Region Children’s Aid Society should revise the Voluntary Youth Services Agreement policy to require that all decision-making is thoroughly documented at all levels, including who made a decision, and written reasons supporting how the best interests, needs and views of the youth were taken into consideration.
Recommendation 17
York Region Children’s Aid Society should provide all frontline staff with comprehensive training on the legislative and policy requirements for Voluntary Youth Services Agreements, as well as its revised VYSA policy. York CAS should ensure this training includes practical information on how to enter into these agreements and what services they cover.
Recommendation 18
York Region Children’s Aid Society should use this report and the experience of Mia and her family as a training tool to demonstrate the impact and importance of service delivery in the context of Voluntary Youth Services Agreements.
Recommendation 19
York Region Children’s Aid Society should provide frontline staff with regular refresher training regarding the legislative and policy requirements for Voluntary Youth Services Agreements.
Recommendation 20
York Region Children’s Aid Society should report back to my Office in six months’ time on its progress in implementing my recommendations, and at six-month intervals thereafter until such time as I am satisfied that adequate steps have been taken to address them.
174 York Region Children’s Aid Society was given an opportunity to review and respond to my preliminary findings, opinion, and recommendations. We also shared a copy of the preliminary report with the Ministry of Children, Community and Social Services. All comments received were taken into consideration in the preparation of this final report.
175 York Region Children’s Aid Society accepted all of the recommendations. In its response, York CAS explained that it remains focused on child, youth and family safety and wellbeing through equitable, child-and-youth-centred, culturally aligned services and building partnerships for a stronger, healthier community.
176 York CAS noted that in recent years, in response to the Ministry of Children, Community and Social Services’ operational review, it has taken numerous steps that address some of the issues identified in my report. For instance, in August 2022, it created a working group to develop a holistic service model for 16- and 17- year-olds. York CAS indicated that this group is developing a service response model that centres young people in planning and decision-making, while maintaining meaningful connections with their family and community. It explained that the recommendations from this report would be incorporated into the group’s work to help ensure it is youth-centred and robust.
177 York CAS has also created a Youth Support Worker position, as well as dedicated youth programming and a Youth Advisory Council that provides feedback and advice on how to continually improve service and care provided to children, youth, and families. In addition, York CAS observed that it has expanded its education liaison program, which supports and empowers young people in attaining their educational goals.
178 With respect to its organizational structure, York CAS highlighted changes to its leadership model that will help ensure that different levels of staff are represented in decision-making. It also noted that a new Chief Executive Officer had been hired, and that there was an internal realignment of departments and department leaders. In addition, York CAS indicated that as of April 2024, it had successfully implemented all of the recommendations from the Ministry’s operational review.
179 I am pleased by York CAS’s positive response to my report and its commitment to improving care for youths seeking or receiving voluntary services. York CAS has agreed to provide my Office with semi-annual status updates, and we will closely monitor its progress in implementing my recommendations.
180 The Ministry was not the subject of my investigation and no recommendations are directed at it. However, I was concerned by the volume and seriousness of complaints that my Office has received relating to Voluntary Youth Services Agreements: 90 complaints about 30 different children’s aid societies since 2019. Accordingly, I provided the Ministry with a preliminary copy of this report, as well as information about the types of complaints my Office has received about VYSAs. I noted that there appears to be considerable uncertainty and inconsistency surrounding the provision and scope of voluntary protection services offered to 16- and 17-year-old children. I suggested that children’s aid societies would benefit from further training and outreach from the Ministry concerning this age group and Voluntary Youth Services Agreements.
181 In its response, the Ministry acknowledged the importance of educating the child welfare sector about how and when VYSAs should be used. The Ministry provided information about steps that it has already taken to increase knowledge within the sector, including attendance at specific association meetings, and said that it will work in collaboration with children’s aid societies, their associations, the Office of the Children’s Lawyer, as well as my Office as it moves forward. Staff from my Office have already met with Ministry staff on several occasions to discuss this issue, and I look forward to further dialogue to improve how children’s aid societies provide services to young people.
____________________
Paul Dubé
Ontario Ombudsman
[1] The name of the youth has been anonymized in this report for reasons of confidentiality. In addition, certain dates, place names, agencies, and identifying details have been generalized or omitted to protect her and her family’s privacy.
[2] Such reports are also required when a child receiving services is seriously injured, and they are known as Death and Serious Bodily Harm reports.
[3] Ministry of Children, Community and Social Services, This link opens in a new tabJoint Directive: Ministry of Children and Youth Services, Ministry of Community and Social Services, Office of the Chief Coroner for the Province of Ontario (26 May 2023) [Joint Directive], online.
[4] Ombudsman Act, RSO 1990, c O.6 ss 14 (1.1)(a) and (4.6)(1).
[5] Child, Youth and Family Services Act, 2017, SO 2017, c 14, Sched 1 [CYFSA].
[6] Ibid, s 35(1).
[7] Ibid, s 35(2).
[8] Ibid, s 3(2-4).
[9] Ibid, s 1(1).
[10] Ibid, s 2(1).
[11] Ontario, Legislative Assembly, This link opens in a new tabOfficial Report of Debates (Hansard), 41st Parl, 2nd Sess, No 44 (22 February 2017) at 2325 (Hon Michael Coteau), online.
[12] Ibid.
[13] CYFSA, supra note 5, s 42 and Ministry of Children, Community and Social Services, This link opens in a new tabPolicy directive: CW 003-18 – Protection Services for 16-17 Year Olds (26 May 2023), online.
[14] Ministry of Children, Community and Social Services, This link opens in a new tabCW 004-21 Protection Services for 16-17 Year Olds (26 May 2023), online.
[15] Mia Ibid.
[16] Ministry of Children, Community and Social Services, This link opens in a new tabProtection Services for 16- and 17- Year-Olds: Information for Youth-Serving Agencies (September 2021), online and Ministry of Children, Community and Social Services, This link opens in a new tabProtection services for 16- and 17- Year-Olds: Information for Youth (September 2021), online.
[17] Ministry of Children, Community and Social Services, This link opens in a new tab2021 Ontario Permanency Funding Policy Guidelines (26 May 2023), online.
[18] Ministry of Children, Community and Social Services, This link opens in a new tab2023 Ontario Permanency Funding Policy Guidelines (30 June 2023), online.
[19] Joint Directive, supra note 3.
[20] Ministry of Children, Community and Social Services, This link opens in a new tabOperational Review Final Report: York Region Children's Aid Society (October 2020), online.
[21] Ibid.
[22] O Reg 155/18, s 7 (1-2).
[23] This link opens in a new tabP.O. v. Family and Children’s Services Niagara, 2012 CFSRB 38 at para 15, online.
[24] Ministry of Children, Community and Social Services, This link opens in a new tabOntario's Quality Service Frameworks: A Resource Guide to Improve the Quality of Care for Children and Young Persons in Licensed Residential Settings (July 2020) at 22, online.