Case Review Summaries

The decision to conduct a case review is made no later than thirty working days following notification of a Fatality, Critical Injury that a child in care or who was served by the Ministry in the previous 12 months. The decision is based on an examination of the critical injury or death using standard criteria. The decision-making process includes consideration of such factors as the nature of the incident, the nature and duration of the Ministry’s involvement, issues or concerns regarding past involvement, and public accountability.

Case reviews begin with the development of terms of reference (TOR) and an examination of relevant case files and electronic records. If the TOR are not answered through this examination, staff and other stakeholder interviews are conducted to ensure the TOR are satisfied. However, interviews cannot be conducted until after criminal investigations and any ensuing court proceedings are completed.

All case review reports include a summary of the family’s involvement with the Ministry or other service provider, an analysis of the information, and a written report. The findings of each case review is reviewed with the Executive Director in the Service Delivery Area or Agency responsible for serving the child. An Action Plan is developed collaboratively to address practice issues identified in the review.  Each action includes the name of the individual accountable for completing it as well as the deadline when it must be completed. The Provincial Director of Child Welfare tracks and monitors the completion of every action in every plan by following up with those accountable for the actions until they are completed.

While it is critical that regional and program staff learn from the circumstances of individual cases in order to improve practice or program and service delivery, it is equally important to consider the organizational learning from case reviews and action them on a system wide basis in a timely manner. In future postings, the Ministry will report on organizational learning from case reviews through aggregate analysis.

Privacy issues are considered when preparing the case review summaries. The summaries do not provide any information such as the child’s age, gender, community, or cause of death or injury in order to ensure the privacy of the child and the family. The public disclosure of information balances the Ministry’s need for a high level of public accountability with its obligations to protect the personal information of the children and families served by the Ministry.