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Dirk Huyer, Ontario’s chief coroner, released his office’s expert panel report into the deaths of 12 young people over a three-year period while they were in the child welfare system. (CBC) Most of the 12 young people who died while in the care of Ontario’s child welfare system had significant mental health challenges but limited or no access to appropriate help, according to a coroner’s report released Tuesday.

The expert panel convened by Ontario chief coroner Dirk Huyer found a litany of other problems, including: A lack of communication between child welfare societies.

Poor case file management.

An "absence" of quality care in residential placements.

Evidence that some of the youth were "at risk of and/or engaged in human trafficking."

Eleven of the young people ranged in age from 11 to 18. The exact age of one of the youth when she died wasn’t clear in the report.

The investigation was struck in 2017. The panel of seven experts in fields including psychiatric care, mental health, working with Indigenous communities and residential placements in Ontario examined how the young people were cared for when they were placed in homes or facilities away from their communities. Grassy Narrows teen’s death to be part of ‘expert review’ of youth who died in child welfare care

"The panel found that most of [the youth] experienced fragmented, crisis-driven and reactionary services and, in some cases, no services at all," the report says.

It also found few families were able to access mental health supports when they were requested.

The panel heard from 13 other young people with experience in the child welfare system, as well as staff from Ontario’s Children’s Aid and Indigenous Child Wellbeing Societies.

In some cases, the 12 young people, eight of them from northern Ontario First Nations with many in remote locations, were placed in care hundreds of kilometres away. The deaths occurred between Jan. 1, 2014, and July 31, 2017.

Eight committed suicide, the report says.

"Throughout these young people’s lives, there were identifiable points where early assessment and intervention may have prevented declining mental health," it says.

"Some of the young people’s families reported requesting support for their children’s mental health very early in their lives and noted that they were not able to receive what they needed."

One girl who died by suicide at age 12 had a history of self-harming for two years before her death, the report said. Despite "intensive intervention" being deemed necessary, she only received limited counselling and was prescribed no medication.

One of the girl’s siblings found her body. Her death was ruled suicide by hanging, according to the report. 8 Indigenous lives The report found their challenges were compounded by a number of other factors, including inadequate shelter on reserve, as well as a lack of clean water and equitable education or health care. In some cases, homes were overcrowded and lacked electricity or running water.Services in First Nations were often deemed inadequate, including youth not having safe places to go when necessary.However, Indigenous youth who were removed from their communities to more urban centres faced other obstacles, like racism — including having things thrown at them — as well as general culture shock, including being removed from connections to elders, land-based teachings and traditional ceremony."The panel found that the services provided to the eight Indigenous young people were largely unresponsive to these needs," the report said. It also said there was little to no culturally appropriate care that focused on prevention and family support.Youth with experience in the child welfare system told the expert panel that the young people often wanted to return to their communities as soon […]

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