Devon’s passing was a terrible loss and Hamilton CAS acknowledges that the system failed Devon (Muska’abo – his spirit name) his grandmother and his community, the Band of Chippewas of Georgina Island First Nation.  We are truly sorry. As an agency we could have done better. Devon has taught us many lessons and will continue to teach us for years to come.

Children’s Aid Societies role is to help families and children by connecting families to communities and community services at the right time. Pam did her very best, and for years advocated for, and participated in, services to get Devon help. No child or youth should have to come under the care of a children’s aid society to get the mental health support they need.

Families who need help are best supported in their own homes through early assistance and prevention programs. Currently the way the child welfare system is funded is based on deficits. This means families get the most support when there are imminent child protection issues, or a child/youth is at risk and removed from their home. With the proper funding from the Provincial government, children’s aid societies can focus more on needs and provide early help, together with community partners, to families before they reach a crisis point.

We have listened and learned from this inquest process.

The inquest has heard that there were communication gaps, issues with the transfer of files and information, between organizations and workers, and a failure to engage Devon’s band. Since his death, significant changes have been made at Hamilton CAS in areas such as training, agency service and communication and partnerships to reduce the risk of a tragedy like this from happening again. Some key changes include mandatory training on Truth and Reconciliation and the harm child welfare has had on Indigenous families, the creation of an Indigenous Team, face to face transfer interviews, and file reviews for all Indigenous youth in care. Together with Indigenous service agencies in Hamilton, the development of the Indigenous Child Welfare collaboration agreement, the development of a protocol for Youth with Complex Suicide Needs, working collaboratively with Indigenous partners on programing, and funding a position at Hamilton Regional Indian Centre to support system navigation and service provision.

The agency will continue to learn, develop relationships with our first nations communities, and continue to change our work to better serve Indigenous families in our community.

There are also serious system gaps in support for Indigenous youth with mental health challenges. In fact, in the Hamilton community, there are no Indigenous specific residential mental health programs, and a very limited number of programs across the province. The residential services that are available are funded as outside paid resources rather than funded as mental health residential services.

When working with Indigenous youth, residential treatment options should be Indigenous run and informed with Indigenous specific programming and staff so that youth can remain in their local community, connected to family, culture and local supports.  These programs should support the involvement of the band and provide a holistic approach to care including the family and community in providing care and support.

As Executive Director Bryan Shone shared in his evidence, we would like to thank Devon’s grandmother Pamela for continuing to advocate for and support the inquest process, and her focus on wanting to be part of improving services. Her grace and attendance at this inquest each and every day has been inspirational. Ms. Freeman, thank you.

The Hamilton Children’s Aid Society thanks the jury for their time and attention throughout this inquest. The agency also thanks the parties for the collaborative and approach to craft a narrative document that was used to highlight specific and particular foundational facts helpful to us all through the inquest process.

From the foundation of these facts, we ask the jury to construct recommendations that will help prevent tragic deaths, in circumstances similar to Devon’s, from happening again. You have been provided with proposed recommendations for your review and consideration. We support all of them. They may be helpful, and provide some guidance, but you as a jury are the final arbiters of what if any recommendations you will deliver to the presiding officer.

Hamilton CAS wants to call attention to several specific recommendations that we believe are key to making a difference. You heard evidence supporting them from Mary Meyer, Bryan Shone and other witnesses.

Child welfare should serve largely as a secondary social safety net for families that fall through the primary social safety net.  Our role is to help families and children by connecting families to communities and community services at the right time to support the safety and wellbeing of children and families.  While many changes have been made, there are recommendations that will help us continue to improve services to Indigenous children, youth and families. These include:

1. Changes to the eligibility spectrum and initial assessment to support a needs-based approach instead of a deficits approach.

• Eligibility and initial assessment are currently focused on harm/risk of harm by commission or omission of a caregiver. Many of the families involved with child welfare are in need of help and support which if not received results in greater risk of harm.  These are areas classified as moderately severe investigations. Focusing on a needs-based approach would better identify areas of strength as well as gaps that might increase risk to a child.

• During initial child welfare assessments, the safety and risk assessment tools used are also deficits based. There must be a verification of concerns based on the caregivers’ actions or inactions rather than assessing areas of strength/safety and environmental, structural, or cultural factors.

2. Development of a process to support a single needs assessment/plan of care focused on the social determinants of health for the family and child that follows them through community services when they are in the community, and in care.

• Currently, child welfare has many plans developed that are isolated from each other and not integrated into a single-family plan (plan of care for CIC, family plan of service, court plan of care, kinship plan of care).  Each are done at different times and do not align in terms of timelines or purpose.

• OPRs and residential mental health programs also have required plans that may not align with child welfare plans and do not follow the family from one program or service to the next.

• Other mental health plans from the community are also completed but may not be integrated into the plans already established within the community. This results in a very disjointed and confusing planning process with families.

3. Supporting joint funding for urban Indigenous agencies, first nations bands, child welfare and local mental health services to increase capacity for collaboration.

• Community based funding, especially for services to Indigenous and racialized community services, is underfunded provincially. This results in those agencies struggling just to address immediate need. Requests for these agencies to sit at community planning tables continues to rise which adds additional pressures and capacity issues.

• Funding for mental health providers and child welfare has not increased in many years and we have heard that Indigenous agencies and bands also do not have the funding to effectively support increased collaboration.

4. As you have heard, the Second Slate includes a number of different funding recommendations directed at the Ministry of Children, Community and Social Services and Ministry of Health. Some of these recommendations request direct, sustainable, equitable and adequate funding while others request that the Ministries seek authority to access necessary funding through government. You, the jury, have the power to recommend that these two Ministries fund these recommendations or seek funding to do so. There is nothing stopping the Ministry from asking the government to fund these services and endeavors.  And they should – we know it would make a difference.

So much knowledge and wisdom has been shared by Indigenous witnesses during this inquest process. We need to use these lessons to guide our work as an agency as we work to implement your recommendations. One key point that resonates for us is the importance of connection to culture and belonging that was shared by Elder John Rice.

There are several conversations that we could have had, and would have now, with Shannon Crate, Chippewas of Georgina Island First Nation, and with Devon, to advance these important connections. With Shannon Crate, when we first received a referral for service, the conversation may have been, “Ms. Crate, we have a family that we are starting to work with that is connected to Georgina Island. We think they could really benefit from a greater connection with their First Nation. How do you think we can work together to support this family?” With Devon when he came into care, it may have gone something like, “Devon, we’ve been in contact with your First Nation and we have a great opportunity to go there to visit so you can learn more about your culture, background and First Nation. We can invite your grandmother. Let’s make some plans.”

These conversations would have been important, and because today, they directly link to two recommendations. The first is one that was shared earlier by our colleague Sarah Clarke, (counsel for the Chippewas of Georgina Island) that supports the development of a communications protocol and offers to initiate quarterly reviews regarding all children receiving services from the Society. Our commitment as an agency is for our Executive Director Bryan Shone to reach out to start this work with Shannon Crate and the Chippewas of Georgina Island First Nation. The second is a recommendation which talks about a ”right to return” for Indigenous youth to return to their home communities when receiving services under the Child Youth Family Services Act (CYFSA).

Moving forward, a holistic approach to how we support children, youth and families with complex needs is essential. Removing children from their homes to access treatment isn’t the solution. Indigenous youth placed in urban settings with no connection to culture is not the answer. We need to enhance communication with bands and support them to have the capacity to work with partners and agencies.

As this inquest draws to a close, we remain committed to working together with Devon’s family, his nation, the Chippewas of Georgina Island First Nation and partners in the community to implement recommendations that would reduce the risk of a tragedy like Devon’s death from happening again and honouring the lessons that Devon continues to teach us.