Staff turnover, higher workload led to breakdown in child death reviews, says deputy minister

Staff turnover and new responsibilities for Coroner Services led to an "unacceptable" breakdown in the provincial child death review process, according to the deputy minister of public safety.

Mike Comeau gave the explanation on Tuesday in response to the auditor general's report that found Coroner Services has not always met its legal obligations in reviewing and reporting on child deaths. 

When Paul Martin issued the report in December, Public Safety Minister Robert Gauvin didn't have an answer as to why the process failed. 

But on Tuesday, members of a legislative committee raised the question again.

"How did we get here?" Green Party Leader David Coon asked.

Lack of support for key changes

Comeau told the committee that he believes issues arose because the Department of Public Safety failed to support Coroner Services through several key changes.

"We lost the chief coroner and another long-serving senior leader of the organization," Comeau said.

"Two people got quite ill, spent a significant amount of time on leave and then retired ... it didn't make for an ideal transition to new leaders coming into the organization." 

At the same time, the office saw an increase in its workload, Comeau said.

"We amended legislation to create more mandatory inquests and to create more requirements, vis-a-vis death review committees," he said. 

"In short, I am not sure that I and my senior leadership team did all that we could have done to wrap our arms around new leadership in this small organization, and make sure they had all the resources they need to not just endure through a difficult transition period, but to excel."

Those issues would have come to a head at the time the auditor general conducted his audit, Comeau said.

He called the result a "devastatingly difficult report to read."

Martin highlighted several gaps in the child death review process, including Coroner Services failing to deliver the committee's recommendations to the relevant institution. 

That requirement is critical, Martin said, as the recommendations are aimed at preventing similar deaths in future.

Pressed on why the office failed to comply with that requirement, Comeau struggled to give an answer. 

"Bottom line is, it was an unacceptable oversight," he said.

Martin's office found no evidence of any committee review for 32 child death cases recorded in 2022 and 2023.

It also found the committee failed to meet its obligation to submit reports to the chief coroner for every child death review. During the audit, the report says the committee held 39 child death reviews but only completed 26 reports.

Comeau said a "new tracking system" was introduced in response to the audit, to make sure all recommendations are delivered as required. 

Martin also found child death review reports were not being made public in a timely manner. 

Coroner Services told Martin's office during the audit that it makes those reports public by tabling them in the legislature— but that also wasn't done consistently . 

"Any instance of non-compliance was — any and all of them were inadvertent," Comeau said. 

"They came out of a lack of appreciation for a detail of a requirement or a procedure, or how a thing was supposed to get done, and not out of a willful decision to fall short of those requirements."

Comeau told the committee that 19 of Martin's 29 recommendations to the department have been completed to date. He said nine more will be completed by the end of March, with the final one expected to be completed in September.