Inquest update and communications - Hamilton Child and Family Supports

October 21, 2022

The inquest into the death of Devon Freeman concluded this week. Devon was an Indigenous youth who was receiving services from Hamilton Children’s Aid Society when he died by suicide. Devon first went missing in October 2017 and his body was found in April 2018 on the property of the youth mental health facility where he was residing.

Devon Freeman’s death was a heartbreaking loss that was felt by all those who knew him and continues to have impact on his family and community. As Hamilton CAS we are saddened his death and acknowledge the loss to both his family and his community.

We wanted to share some key highlights from the final week of the inquest.

The final week of the inquest began with a panel speaking about Indigenous programming and cultural safety. The panel spoke to the importance of customary care, the need for cultural services to be available for Indigenous children and youth services and barriers to mental health services for Indigenous youth. The jury has heard about a committee with representatives from Ministry of Health, MCCSS, mental health agencies and CAS, and how to move forward recommendations to support a residential placement system that integrates Indigenous land based and cultural competencies.

The jury heard from factual witness Vanessa Henry, Devon’s primary worker at Hamilton Regional Indian Centre (HRIC). She shared that she was unaware of Devon’s mental health concerns or suicidal ideation. She spoke of the benefits of working together with other community partners to wraparound youth and let them know they are supported. Elder John Rice, the last witness to testify, shared Indigenous teachings and perspectives on health and healing. He shared information on mental health wellness from an Indigenous perspective and how these approaches may differ from mainstream psychology. He spoke of the life journey as a holistic approach and how to change the dialogue of illness into one of wellness.

In closing submissions, the jury heard that there are two slates (lists) of recommendations that have been developed, 73 in total. There is a one list that all those involved in the inquest agree upon, and a second list that all parties support except for the Ministry of Children, Community and Social Services. Various parties presented their closing submissions to the jury, highlighting recommendations that they feel are important for the jury to consider. Hamilton CAS presented its closing submission to the jury. The full closing submission can be found on the agency website here.

On the final day of the inquest, the jury presented their verdict and 75 recommendations, three which were added by the jury. The recommendations can be found here. Following the adjournment of the inquest, a healing closing ceremony was held. Everyone in attendance sat in a sharing circle. Devon’s grandmother and sister were gifted with blankets and jurors were all given artwork in recognition of their service. Everyone received a bookmark and beaded keychain in honour of Devon and participated in a round dance.

October 17, 2022

The inquest into the death of Devon Freeman continued into its third week. Devon was an Indigenous youth who was receiving services from Hamilton Children’s Aid Society when he died by suicide. Devon first went missing in October 2017 and his body was found in April 2018 on the property of the youth mental health facility where he was residing.

We wanted to share some key highlights from the past week.

Shannon Crate, Band representative from the Band of Chippewas of Georgina Island First Nation shared her experience as a prevention worker on Georgina Island and the importance of Children’s Aid Societies working together with the Band and Indigenous community to support Indigenous children, youth and families. Shannon shared the impact of learning about Devon’s death upon receiving a faxed death certificate, rather than being contacted by Hamilton Children’s Aid Society. The jury also heard about the significance of the inquest and using it to honour Devon’s legacy to support meaningful changes.

The jury heard from expert witness Dr. Peter Braunberger, a psychiatrist specializing in child and adolescent psychiatry. Dr. Braunberger agreed with the psychiatric care Devon was given and felt that Devon’s suicide was surprising. He shared that Devon did appear to pull away from supports in the past year of his life and highlighted some key areas of importance in providing support to vulnerable youth include having trusting relationships, attachment to culture, and the importance of looking more broadly at a social model than strictly medical model.

A panel from the Ministry of Children, Community and Social Services provided an overview of child welfare laws and policies, the Ontario Indigenous Children and Youth Services strategy, coordination agreements between First Nations and the Provincial and Federal governments, the ongoing plan for redesign of child welfare and how the Ministry reviews Serious Occurrence Reports.

An Indigenous Psychology and Life Promotion Panel with Dr. Ed Connors and Dr. Brenda Restoule, leaders in mental wellness and use of cultural practice for life promotion for Indigenous youth, addressed practices, treatments and connections in Indigenous psychology and programming that are of value to an Indigenous youth to effect meaningful wellness and promote life. They provided an overview of using Indigenous culture as a protective and preventative measure in mental health support to addressing the systemic, historic and individual harm Indigenous people experience and provided some proposed recommendations to the jury.

A best practice police panel shared an overview of strategic planning, missing person units, the role of the Missing Person’s Coordinator and the role of civilians and proactive problem solving through focus tables and multi-disciplinary and inclusive approaches. The panel highlighted the need for informed risk assessments, ensuring suicidal ideation is flagged and how to address young people who repeatedly go missing.

Lisa Whittaker the Executive Director of Lynwood Charlton, and Bryan Shone, Executive Director of Hamilton CAS, were the next systemic witnesses that spoke about system gaps and challenges that exist for Indigenous children, youth and families served by the mental health and child welfare systems, the importance of early help for children, youth and families, the need for collaboration between Child Welfare, Indigenous Communities and Mental Health Services. Key points included looking at needs instead of placements, being able to provide the right supports at the right time and some recommendations for the jury.

The inquest resumes October 17, 2022.

October 11, 2022

The inquest into the death of Devon Freeman continued into its second week. Devon was an Indigenous youth who was receiving services from Hamilton Children’s Aid Society when he died by suicide. Devon first went missing in October 2017 and his body was found in April 2018 on the property of the youth mental health facility where he was residing.

Through evidence presented at the inquiry, it was identified that in 2017 when Hamilton Children’s Aid Society was working with Devon, there were gaps in communication and the collection and review of information between departments and with community organizations. The agency has made numerous changes to policy and internal processes to increase collaboration and involvement of families in decision making.

Additional highlights from the second week of the inquest.

The inquest continued with factual witnesses and the jury heard about recommendations from the third-party review that Lynwood conducted, Ministry licensing requirements for the facility, serious occurrence reports and funding limitations.

The jury heard from Kim Loiselle, the Children’s Services Worker who worked with Devon. They heard information contained in intake/family services and children services files and serious occurrence reports as well as several changes that have happened at the agency to increase collaboration with Band representatives and serving Indigenous children, youth and families.

Dr. Sassi, a psychiatrist who treated Devon provided an overview of his work with Devon and an explanation of medical diagnoses. He also commented on limited residential placement options for youth experiencing mental health issues.

The jury heard from Sharri Watson, the Extended Society Care Worker who worked with Devon after he became a crown ward with a focus on file transfers between workers, coordination with police when Devon went missing and the need for more community resources for youth with mental health needs.

Mary Meyer who was a Director of Service and Interim Executive Director in 2017 provided testimony on changes that have been made to better support children and families in their homes including a new service structure, increased collaboration with Indigenous partners, the agency’s third-party Internal Death Review, recommendations and the agency’s response to the Coroner’s Pediatric Death Review and Ministry standards for child welfare.

Kim Walker, a missing persons coordinator with Hamilton Police Services testified about HPS processes and recommendations related to missing persons.

The inquest resumes October 11, 2022.

October 3, 2022

The inquest into the death of Devon Freeman is underway. Devon was an Indigenous youth who was receiving services from Hamilton Children’s Aid Society when he died by suicide. Devon first went missing in October 2017 and his body was found in April 2018 on the property of the youth mental health facility where he was residing.

We wanted to share some key points from the first week of the inquest.

Devon was a member of the Chippewas of Georgina Island First Nation. A pow wow was held in Georgina which included a run and sacred ceremony to honour Devon’s memory and the first day of the inquest was held on Georgina Island.

The purpose of the inquest was outlined, including how and why someone died and recommendations to prevent similar deaths in the future rather than laying blame.

Moving testimony was provided by Pamela Freeman, Devon’s grandmother, who shared; “My hope for Devon was always to find ways to show him how incredible he actually could be. He needed a vision and to get there would give him a sense of purpose. The loss of his mom at such a young age created so much unresolved healing. May his legacy be one of hope so that not one more child will end their story way too soon.”

A Narrative was introduced to the jury. This narrative was developed collaboratively by parties involved in the inquest, including Devon’s grandmother and the Band. It highlighted specific and particular facts that the parties feel impacted Devon’s life and contributed to the trajectory of his path towards his death.

The format of the inquest was shared. It has been divided into testimony from factual and systemic witnesses. September 28 and 29 focused on witnesses from Lynwood Charlton Centre, the youth mental health facility centre where Devon was living at the time of his death. The inquest did not sit on September 30 the National Day of Truth and Reconciliation.

Throughout preparations, and during the inquest, Hamilton CAS is focusing on four guiding principles. These, along with a statement are posted on our website at Inquest update and communications – The Children’s Aid Society of Hamilton (hamiltoncas.com). If you have any questions, please feel free to send them along to inquest@hamiltoncas.com and we will get back to you.

September 16, 2022

September 26, 2022 is the start of the inquest into the death of Devon Freeman, an Indigenous youth who was receiving services from Hamilton Children’s Aid Society when he died by suicide. Devon first went missing in October 2017 and his body was found on the property of the youth mental health facility where he was residing in April 2018.

Hamilton CAS supports the decision of the coroner to call this inquest into Devon’s death. We are committed to working together with Devon’s family, his nation, the Chippewas of Georgina Island First Nation and partners in the community to help identify and implement recommendations that would reduce the risk of a tragedy like Devon’s death from happening again.

As the inquest approaches, we want to share our commitment to open and transparent communications so that staff are informed and supported, and the community understands our commitment to working with our Indigenous partners and families to review and recommend areas where Devon and his family could have been better served if the right supports were available at the right time.

Guiding principles

Throughout preparations, and during the inquest, Hamilton CAS will focus on four guiding principles:

1. The Children’s Aid Society of Hamilton acknowledges that we are accountable to review and revise our internal processes in an open and transparent manner and learn from Devon’s tragic death.

2. The Children’s Aid Society of Hamilton acknowledges that the best service and support is provided to Indigenous children when we work collaboratively with their community. During the inquest we will aspire to work closely with the Chippewas of Georgina Island First Nation and community partners with the goal of assisting the Coroner and jury to develop recommendations that will honor Devon and influence systemic improvements.

3. The Children’s Aid Society of Hamilton acknowledges that there is a need to enhance ethno-specific services and supports to Indigenous children, youth, and families within the community as well as across Ontario. We believe that the inquest process will involve reviewing and recommending areas where Devon and his family could have been better served if the right supports were available at the right time.

4. The Children’s Aid Society of Hamilton acknowledges that we need to all work together as community organizations to develop a joint coordinated plan for families and children to best support their needs and to have their voice help guide a community response to their needs which include the social determinants of health.