BC CORONERS SERVICE DEATH REVIEW PANEL: Review of MCFD-Involved Youth Transitioning to Independence January 1, 2011 – December 31, 2016 REPORT TO THE CHIEF CORONER OF BRITISH COLUMBIA May 28, 2018 CONTENTS EXECUTIVE SUMMARY .................................................................................................................................. 3 VIGNETTES ................................................................................................................................................ 5 DEATH REVIEW PANEL .............................................................................................................................. 7 PART 1: INTRODUCTION ............................................................................................................................... 8 CHILD WELFARE SERVICES IN B.C. ............................................................................................................. 9 PART 2: BC CORONERS SERVICE INVESTIGATIVE FINDINGS........................................................................ 12 A. THE YOUNG PEOPLE WHO DIED ..................................................................................................... 12 Classification of Death ........................................................................................................................ 13 Classification and Means of Death...................................................................................................... 14 Indigenous Youth and Young Adults (N=68) ....................................................................................... 14 First Nations perspectives on health and wellness ............................................................................. 16 B. LIFE CONTEXT .................................................................................................................................. 17 Social Determinants of Health ............................................................................................................ 18 Health and Well-being ........................................................................................................................ 20 Service Utilization and Stressors and Barriers .................................................................................... 21 PART 3: TRANSITION PLANNING ................................................................................................................. 23 PART 4: SPECIALIZED INVESTIGATIONS....................................................................................................... 26 PART 5: RECOMMENDATIONS .................................................................................................................... 27 DATA LIMITATIONS AND CONFIDENTIALITY ............................................................................................... 31 APPENDIX A – DATA TABLES ....................................................................................................................... 32 APPENDIX B – MCFD SERVICE DESCRIPTION .............................................................................................. 33 GLOSSARY.................................................................................................................................................... 35 REFERENCES AND BIBLIOGRAPHY ............................................................................................................... 38 Page 1 PREFACE On December 7, 2017, the British Columbia Coroners Service (BCCS) held a death review panel regarding persons who died while transitioning from youth to adulthood and who had extensive Ministry1 or support service involvement. In the six-year period reviewed, 200 young people died. The review of the circumstances that resulted in their deaths provided panel members with valuable information to consider what could be done to prevent similar deaths. This report is dedicated to the families, friends and communities who lost loved ones. Panel support was provided by BCCS staff. Cara Massy provided administrative support and Carla Springinotic, Adele Lambert and Andrew Tu prepared the file-review analysis and background research which formed the basis of the panel discussions, findings and recommendations. I am sincerely grateful to the following members of this panel for sharing their expertise, bringing the support of their respective organizations and participating in a collaborative discussion. I would also like to recognize the contributions of Ian Pike and Kora DeBeck for their input. The participants’ contributions have generated actionable recommendations that I am confident will contribute to addressing deaths of young persons in British Columbia (B.C.). Brittaney Andreychuk – Federation of BC Youth in Care Networks Dr. Tyler Black – BC Children’s Hospital Chief Bob Downie – Saanich Police Superintendent Jim Falkner – RCMP Island District Linda Hughes – Office of the Representative for Children and Youth Keva Glynn – Ministry of Mental Health and Addictions Dr. Perry Kendall – Provincial Health Officer Jennifer McCrea – Ministry of Education Dr. Shannon McDonald – First Nations Health Authority Nazeem Ratanshi – Fraser Valley Aboriginal Child and Family Services Kevin Reimer – BC Principals’ and Vice-Principals’ Association Billie Joe Rogers – Reciprocal Consulting Deborah Rutman – University of Victoria Alex Scheiber – Ministry of Children and Family Development Annie Smith – McCreary Centre Society Trilby Smith – Vancouver Foundation Michelle Wywrot – Ministry of Children and Family Development On behalf of the panel, I submit this report and recommendations to the chief coroner of B.C. Michael Egilson, Panel Chair 1 All bolded terms are defined in the glossary. Page 2 EXECUTIVE SUMMARY Adolescence is a time of exciting and intense change. The process of moving from childhood to adulthood can be challenging for young people. For many young people, family continues to provide guidance and support well into early adulthood; however, youth transitioning to adulthood from government care face an additional, simultaneous transition from government support to independence often without similar resources, family support or guidance, and at a younger age than their peers. This report reviews the deaths of vulnerable youth and young adults who had been in government care or were receiving extensive support services and who died during their transition to adulthood. For the period of January 1, 2011 to December 31, 2016, 1,546 youth and young adults aged 17-25 years died from causes classified as accidental, suicide, undetermined, natural or homicide. Of these deaths, 200 (13%) deaths were among youth and young adults who at age of death or at age of majority were in care, were former children in care, or were on independent youth agreements or receiving extensive support services. These young people leaving government care died at five times the rate of the general population of young people in British Columbia. Although many young people leaving care or youth agreements show great resilience and strength as they transition to adulthood, they also face many more challenges than their peers. They may lack a family support network, have limited or no financial resources, often lack life skills, and often have not completed school. They may suffer from low self-esteem and be scarred by trauma associated to violence, childhood neglect and/or abuse. To better understand these deaths and identify prevention opportunities, a death review panel appointed under the Coroners Act was held in December 2017. The circumstances of 200 young people who died while transitioning to independence from government child services between January 1, 2011 and December 31, 2016 were reviewed in aggregate. The panel was comprised of professionals with expertise in youth services, child welfare, income support, mental health, addictions, medicine, public health, Indigenous health, injury prevention, education, law enforcement and academia. The review found:       A lack of documented transition planning for youth leaving care or on youth agreements; A disproportionate number of Indigenous young people died; High rates of suicide and drug overdose deaths; High rates of health and mental health issues; Lower completion of educational attainment; and, Barriers (systemic and personal) to successfully transition to independence. The panel identified four key areas to reduce the deaths: 1. Extending service supports based on the young person’s needs; 2. Improved communication between service providers with the goal to increase engagement of youth; Page 3 3. Engage with youth on service planning and policy development; and, 4. Monitor outcomes and use findings to support service planning and policy changes. These findings are the basis for the following recommendations put forward to the chief coroner by the panel. Recommendations #1: Expand Agreements with Young Adults (AYAs) to Address Self-Identified Transition Needs:  By April 2019, the MCFD will consult with youth, Delegated Aboriginal Agencies and frontline staff about how best to administer AYAs (e.g. youth needs for ongoing supports, ease of accessibility).  By October 2019, the MCFD will amend the qualifying criteria for AYAs so that all young people transitioning from care or Youth Agreements are universally eligible for the program. Services and financial support provided will address unique circumstances and transition needs of the young person. Recommendation #2: Ensure Collaboration to Support Effective Planning and Service Provision:  By April 2019, MCFD in collaboration with Indigenous and other stakeholders (health, mental health, police, education, community service providers) will develop processes or protocols to improve ongoing information sharing to better meet the planning and support needs of youth in care.  By April 2019, the MCFD will consult with youth and Indigenous partners on an ongoing basis to identify needs and services that would assist young people to successfully transition to adulthood.  By October 2019, the Ministry of Education will ensure that all children in care have a plan to support their educational needs.  By December 2019, the Ministry of Mental Health and Addictions will collaborate with the MCFD, Ministry of Health and First Nations Health Authority to ensure access to youth mental health and addictions services for youth transitioning from care or on Youth Agreements. Recommendation #3: Monitor Support Service Effectiveness for Youth Leaving Care:  By April 2019, the MCFD will consult with young people in care, formerly in care, or on Youth Agreements and Indigenous partners to develop transition and AYA outcome indicators.  By October 2019, the MCFD will develop a plan to monitor and evaluate transition planning and outcomes and AYA outcomes. Page 4 VIGNETTES Although this review looks at deaths of youth transitioning from government care and services in aggregate, the young people who died were individuals who had hopes and dreams. The following vignettes provide actual examples (the names have been changed) of these deaths and are representative of many of the circumstances found throughout the review which form the basis of the report’s recommendations. Chris’s Story Chris was a young person who was described as hard working and empathetic, but was also known to experience periods of depression, anxiety and loneliness. Family conflict, exposure to domestic violence, parenting issues and neglect had brought Chris into contact with MCFD family supervision services from a young age. During her teenage years, Chris’s relationship with her family deteriorated, and she entered into a Youth Agreement with the Ministry of Children and Family Development. Chris was provided independent housing and connected with youth-support workers and counsellors. While on a Youth Agreement, Chris attended school regularly. Chris graduated from high school and had plans to start post-secondary education. Her social worker provided support and discussed transition planning. As part of the transition planning, Chris had learned to cook, was working toward finding employment, getting a driver’s licence and finding an apartment. Throughout this time, Chris met with youth support workers with whom she had a good relationship. Although Chris was engaged with moving forward in her life, investigative notes indicated that she was concerned about transitioning to independence, finding housing, losing supports and being able to manage the responsibilities of being independent. Tragically, Chris’s plans for work and further schooling were suddenly interrupted by the deaths of two loved ones. To cope with the pain and loss, she began using illicit substances on a daily basis. Counselling and addiction treatment options were offered, but Chris was unable to participate. Two months before her Youth Agreement was set to expire, Chris died of an illicit drug overdose. Pat’s Story Pat was described as being a good listener and often took a leadership role when participating in group activities. He came into the care of the Ministry of Children and Family Development at a young age. Throughout his childhood, Pat experienced considerable challenges in his life related to behaviour, mental health, unstable living environments, and difficulty in school. He received community services including psychological assessments, mental health services through Child and Youth Mental Health and had an individual educational program with supports at school. Although Pat had frequent contact with his social worker, his documented Care Plan was not current. At the time of his death, he had completed some Grade 11 course work. Page 5 Pat had difficulties managing his emotions, adapting to change and making or maintaining friendships. He began consuming alcohol in his early teens and was self-harming. Seven months before his death, Pat attempted suicide after an argument with a friend. As Pat neared his 19th birthday, he expressed concerns about feeling increasingly anxious about living independently. He worried that he would be alone without support. To prepare Pat for living independently, he was enrolled in a program that provided training/education in job readiness, and arrangements were made for Pat to move from his foster home into an apartment with a roommate. The move went smoothly, and Pat was helped with setting up his new home. Shortly after this move, Pat had an argument with his new roommate. He was found in his bedroom; his death was a suicide. Page 6 DEATH REVIEW PANEL A death review panel is mandated2 to review and analyze the facts and circumstances of deaths to provide the chief coroner with advice on medical, legal, social welfare and other matters concerning public health and safety and prevention of deaths. A death review panel may review one or more deaths before, during or after a coroner’s investigation, or inquest. Panel members were appointed by the chief coroner under Section 49 of the Coroners Act, including professionals with expertise in public health, health services, substance use, mental health, Indigenous health, education, income assistance, child welfare, youth services, policing and academia. Regardless of their employment or other affiliations, individual panel members were asked to exercise their mandate under the Coroners Act and express their personal knowledge and professional expertise. The findings and recommendations contained in this report need not reflect, or be consistent with, the policies or official position of any other organization. In the course of reviewing deaths of youth transitioning from government services, the panel reviewed:       BCCS investigative findings; Information provided by panel members; Environmental, social and medical factors associated with the deaths; Possible trends or themes; The current state of related public policy and strategies; and, Existing challenges. The panel collectively identified actions for improving public health prevention processes with respect to deaths among youth transitioning from care. 2 Under the Coroners Act Page 7 PART 1: INTRODUCTION Early experiences in childhood impact many aspects of an individual’s development and are foundational to lifelong health and development. A strong, loving relationship between a parent and child supports a child’s healthy growth and development. Addressing the root causes for neglect and ensuring that families have access to services and supports (e.g. social connectedness, financial, housing, and health care) help children to get the best start in life. Providing family support and early interventions is a key strategy to reduce the need for a child’s entry into government care. Additionally, given the over-representation of Indigenous children in care, this requires respecting and working in true partnership with Indigenous communities. “A child who has the physical, mental/emotional, cognitive, social relationship and material well-being aspects of his or her life well supported and balanced has a good chance of more smoothly navigating the road of life and reaching his or her potential” (Provincial Health Officer [PHO], 2013). In Canada, provinces and territories are responsible for providing services to children who have been either abused (physically, sexually or emotionally) or neglected by their parents or primary caregiver(s). If a child is in need of protection, the government may assume responsibility, either on a temporary or permanent basis, for the child. “Like all children, children in the care of the government have hopes, dreams and aspirations; many have the resilience to overcome the obstacles they face and to live happy and healthy lives. However, children in care are known to have generally poorer outcomes than children who have never been in care. As the guardian of these children, government has a special responsibility to develop strategies to improve these outcomes” (PHO, 2007). Early childhood exposure to trauma is associated to a range of physical and mental health outcomes, and has effects on brain development. Stability of care and emotional security during time in care are significant predictors of young people’s outcomes. Early intervention services and transition planning should begin as early as possible to support success. (Wiens, M, 2014) When youth age out of the child welfare system, they experience two simultaneous transitions: the transition from the care, protection and supervision of the child welfare system to that of independence; and, the transition from childhood to adulthood (Goodkind, Schelbe, & Shook, 2011). Most youth leaving care do not have the financial, medical or social support tools to successfully transition to independence. Youth leaving government care typically lack a safety net. They are unlike their peers, who often transition to adulthood around age 23 and may rely on parents for on-going support during early adulthood (Goodkind et al., 2011). A survey of former youth in care found that they don’t have anyone else to ask for guidance or advice, and for many youth, program staff were a substitute for the limited support from family and other informal networks (Paulsen & Berg, 2016). Page 8 The challenges experienced by youth leaving care at age of majority are compounded by systemic issues (Kovarikova, 2017). These systemic issues include:  In B.C., as of November 2017:  1,015 youth were in care by continuing custody order  654 youth had a Youth Agreement  131 youth in care by interim/temporary custody order  298 youth were in care by voluntary or special needs agreements  79 youth were receiving youth services  380 youth aged out of care (over past 8 months)  433 young persons (age 19 to 26 years) had an Agreement with Young Adults (AYA)  Youth includes those persons age 16 years up to 19 years (Source: MCFD 2017)     The requirement that youth transfer to adult programs and new service providers; The termination of coordinated case management by a primary social worker resulting in a lack of coordination and communication among various services; The loss of established, trusted relationships due to no further involvement of foster parents, youth mental health teams and youth counsellors or other youth service providers; Limited youth employment opportunities and a scarcity of housing and supervised living arrangements; and, A lack of affordable educational services, and a shortage of mentors. CHILD WELFARE SERVICES IN B.C. In B.C., child welfare services are delivered through the Ministry of Children and Family Development (MCFD) under the Child, Family and Community Service Act (CFCSA). MCFD programs and services are coordinated through a provincial office and delivered through 13 geographical service delivery areas or by Delegated Aboriginal Agencies (DAAs) that have signed agreements with the ministry (BC Government, 2017). Annually in B.C., MCFD child protection workers receive approximately 37,000 reports of children in need of protection. Of these, approximately 3,328 go into care for child protection reasons. Most admissions to care (75%) are by removal and subsequent custody orders (e.g. continuing custody orders (CCO), temporary custody orders (TCO)) while 25% of children enter care by agreement with parents (e.g. voluntary care agreements (VCA), Special Needs Agreements (SNA)). In B.C. and in Canada, the number of Indigenous children in care is significantly disproportionate to the number of Indigenous children in the general population. Indigenous children and youth in B.C. are 15 times more likely to be in care than non-Indigenous children and youth (Grand Chief Ed John, 2016). For some youth who are living outside of their family home and cannot return to live with family or extended family, the MCFD may provide initial support through Support Services for Youth (SSY) and ongoing support through a Youth Agreement (YAG). YAGs offer an out of care alternative to youth aged 16-18 years who are in need of assistance. Youth who enter into YAGs often have significant life issues such as: homelessness, behavioural or mental health disorders, severe substance use, or are at risk of Page 9 sexual exploitation. YAGs may provide residential, educational, financial and other support to youth in return for their commitment to work with service providers on a plan for independence (BC Government, 2017). Each year in B.C., approximately 4,316 children and youth are discharged from care, and of these, 780 age-out of care when they reach the age of 19 (Plecas, 2015). When youth in care or on Youth Agreements reach their nineteenth birthday, they have reached the age of majority and are considered adults. They leave their social worker, their youth worker, their foster family or other support persons. For many youth, there is no longer a case manager overseeing their services. They may be transferred to new adult service providers, or may no longer have access to mental health supports or services. They lose access to financial, education, and social supports provided through the child welfare system. They are now responsible for independently managing all aspects of their life and care needs. The MCFD provides some extended support to qualifying youth through an Agreement with Young Adults (AYAs). This program supports young adults, aged 19 to 26, who were previously in care or had a Youth Agreement with the ministry. Young adults can submit an application for financial support and assistance to: complete high school, attend a post-secondary educational or vocational training program, attend an approved life skills program or complete a rehabilitative program. Financial assistance may include living expenses, child care, tuition fees and health care. Persons accessing AYA supports need to complete one of the following requirements:     60% course load in an educational or skills training program (40% if you have a permanent disability) A minimum of 15 hours a week participation in a rehabilitation program A combination of educational / skills training and rehabilitation program time that equals at least 15 hours a week An approved life skills program that is at least 12 hours a week (or 48 hours per month) Although a variety of frontline staff can complete an assessment for AYA eligibility, those who have developed working relationship with the youth typically do not administer the AYA program. Instead AYA administration is primarily a financial transaction; missing the local, in-person contact and supportive connection. Research suggests the leaving care transition needs to be flexible, gradual and well-planned. This includes individual transition planning based on the young person’s needs, flexible post-care options and ongoing emotional and financial support (Mendes, Johnson, & Moslehuddin, 2011). Page 10 Multiple agencies and ministries may be involved in independence planning and to support youth transitioning from care to adulthood. There is currently no process for monitoring outcomes of children formerly in care or formerly on Youth Agreements. B.C. data indicates that between January 1, 2011 and December 31, 2016, there were 200 deaths of youth and young adults transitioning from government care or extensive services. These young people died at five times the rate of the general population of young people in B.C. To better understand where, how, and why these deaths are occurring, the BCCS convened a death review panel. Page 11 PART 2: BC CORONERS SERVICE INVESTIGATIVE FINDINGS For the period of January 1, 2011 to December 31, 2016, there were 200 deaths among youth and young adults who transitioned from care or from extensive government services. These 200 deaths represent 13% of all youth and young adult deaths. This report is based on investigative findings of persons who died who were:     Youth in continuing care, under temporary custody orders or care agreements at time of death; Young adults who were formerly in continuing care, under temporary custody orders or care agreements at age 19; On Youth Agreements at time of death or at age 19; or Receiving extensive support service involvement (e.g. child youth mental health (CYMH) services, Child Protection (CP), Family Services (FS) or youth justice service) at time of death or at age 19. The report also includes additional analysis of life context data for a smaller a cohort of 82 youth where additional investigative details were available. A. THE YOUNG PEOPLE WHO DIED Of the 200 youth and young adults (aged 17-25) who died (2011-2016):   117 decedents were identified as youth in care or on Youth Agreements: o 34% (n=68) were in care at time of death or at age of majority; and, o 24% (n=49) were on Youth Agreements at time of death or at age of majority, and one decedent was on an Agreement with Young Adults. 83 decedents (42%) were not in care, but were receiving extensive supports or services at time of death or at age of majority (See Table 1). Table 1 MCFD Service Type by Age*, 2011-2016 17-18 Years In Care (CCO, TCO, VCA, or SNA) 17 Youth Agreements (YAG & SSY) 7 Extensive Services 8 Total 32 *at time of death or at age of majority 19 Years 5 7 5 17 20-25 years 46 35 70 151 Total (%) 68 (34%) 49 (24%) 83 (42%) 200 Page 12 Sex This review (n=200) found that more males died than females. Almost two-thirds of deaths (63%) were among male youth and young adults, whereas 37% of deaths were among female youth and young adults. Age This review (n=200) found that 16% of the young persons who died were age 17-18 years, 8% were 19 years, and 75% were 20-25 years of age. As shown in Table 1, there were 17 youth (8%) who died within the year of reaching the age of majority (age 19). None of the 19 year olds who died were accessing supports through Agreements with Young Adults (AYAs). Of the 20-25 year olds who died, 54% were former children in care, on Youth Agreements or Special Needs Agreements. Only one 20-25 year old who died was known to be accessing supports through an Agreement with Young Adults (AYAs). Health Authority Of the 200 young persons who died, half lived in the lower mainland. Almost one-third (30%) were residents of Fraser Health, 20% were residents of Vancouver Coastal Health Authority, 18% were residents of Interior Health, 17% were residents of Island Health, and 15% were residents of Northern Health. Classification of Death Of the 200 youth and young adults who died (see Table 2):     Almost two-thirds (61%) of deaths were due to accidental causes; Suicides accounted for 24% of deaths; Homicides accounted for 7% of deaths; and Natural diseases (4%) and undetermined causes accounted for 3% of the deaths. Table 2: Number of Deaths by Classification and MCFD Service Type*, 2011-2016 In Care Youth Agreements Accidental 44 Homicide 5 Natural 5 Suicide 13 Undetermined 1 Total 68 29 7 2 10 1 49 2 14 1 8 26 49 4 6 83 200 Extensive Services 50 Total 123 *at time of death or at age of majority Page 13 Classification and Means of Death Of the 123 accidental deaths occurring within the cohort (n=200):    89 deaths (72%) were related to illicit drug overdoses; 18 deaths (15%) were caused by motor vehicle collisions; and, The other 16 deaths (13%) were due to drowning, exposure, fire, fall, asphyxia, or other traumatic injuries. Some natural deaths may be prevented. Of the eight natural deaths included in this review:   Six deaths were related to conditions arising from illicit drug use; and, The other two natural deaths were due to a cardiac condition and cancer. A death review panel report on illicit drug overdose deaths released April 5, 2018 identifies public safety and prevention actions to reduce overdose deaths. Indigenous Youth and Young Adults (N=68) This review found a disproportionate representation of deaths among Indigenous young persons compared to the number of Indigenous young people in the general population. The reasons that Indigenous youth and young adults die are similar to their non-Indigenous peers (BCCS, 2017). Indigenous youth and young adults accounted for 34% of the 200 deaths. Of the 68 Indigenous youth and young adults who died:    50% (n=34) were in care at time of death or at age of majority; 25% (n=17) were on Youth Agreements at time of death or at age of majority; and 25% (n=17) were not in care, but were receiving extensive supports or services at time of death or at age of majority. Indigenous youth receive services through either the MCFD or one of the Delegated Aboriginal Agencies depending upon where the young person lived and the supports required by the young person. More Indigenous males died than Indigenous females (66% compared to 34% respectively); this is similar to their non-Indigenous peers. The age and sex distributions were dissimilar for Indigenous young persons contrasted those of their non-Indigenous peers. In this review, 35% (n=24) of Indigenous decedents were aged 17-19 years, and 65% (n= 44) were age 20-25 years (see Table 3). Page 14 Table 3: Number of Deaths, Indigenous Young Persons, Age and Sex, 2011-2016 Age 17-18 Years 19 Years 20-25 years Total Total Deaths (Female) 6 4 13 23 (34%) Total Deaths (Male) 9 5 31 45 (66%) Total Deaths 15 9 44 68 This review found that:    Nine Indigenous youth died within the year of reaching the age of majority (age 19); Five Indigenous youth who died had transitioned from being children in care; and, Three youth who died had been on youth agreements. The opportunity for B.C., Canada and Indigenous governments, communities, and families to work in partnership to recognize, constructively address, and reconcile our respective interests to better support the needs of all Indigenous children has never been greater (Grand Chief Ed John, 2016). A 2016 death review panel report of First Nations youth and young adult injury deaths, published in 2017, highlighted that culture and the inter-connectedness of individuals, families, communities and First Nations play an integral role in health and wellness for First Nations people. Some First Nations communities and individuals have collective and individual factors in their lives (e.g. historical trauma, colonization, poverty, powerlessness, and/or other stressors) that may impact health and wellness. Evidence has established an association of certain social determinants with injury and an influence on health and wellbeing. Indigenous specific social determinants of health include: colonization, colonialism, racism, marginalization, dislocation, social exclusion, self-reliance and self-determination (Greenwood, 2015). Indigenous youth in government care often suffer diminished connections with family and friends. Having the support of caring adults was revealed to be particularly significant for this population. Among Indigenous students with experience in government care, those who had an adult to turn to if they had a serious problem were less likely to report extreme stress. Youth who felt they had an adult who cared for them were also more likely to rate their mental health more highly (Tourand, J., Smith, A., Poon, C., Saewyc, E., & McCreary Centre Society, 2016). Given the disproportionate number of Indigenous children in care, it is important to understand Indigenous perspectives on health and wellness when providing services. Page 15 Source: First Nations Health Authority First Nations perspectives on health and wellness The First Nations Perspective on Health and Wellness, as illustrated above, provides a holistic framework and visual aid for understanding how the health of individuals, families, communities, and nations are related and interconnected. This interpretation is based upon traditional concepts of wellness that have been passed down from Elders and traditional healers, as well as feedback and input gathered at community engagement forums such as Gathering Wisdom events over the last several years. The centre circle represents the individual human being. Health and wellness begins with the individual taking responsibility for their own health and well-being to the best of their ability. Moving outwards from the centre are the mental, spiritual, emotional, and physical aspects of health. When these four domains are balanced, they contribute to a life that is lived healthy and well. The third circle contains the core values that are the foundation of wellness. Respect, wisdom, responsibility, and relationships are all central to achieving balance, wellness, and right relations within Creation. When these values are brought into everyday life, they can support a healthy and balanced life. The fourth circle represents the peoples and things with whom relationships are formed. The individual human being is part of a complex set of relationships as a member of a family. Individuals are from a particular place and have a relationship with the land upon which they were born. Communities may be Page 16 composed of a collective of knowledge, interests, experiences, or values. Nations include an extended community of families and kinships. All of these relationships are central to good health and well-being. The fifth circle signifies the social, cultural, economic and environmental conditions in which First Nations peoples attempt to achieve and maintain health and wellness. These ‘determinants’ are largely external to the mainstream health care system, but they play a large role in creating environments that can support health and well-being. Social determinants include necessities such as food, housing, education, health promotion and safety. Environmental determinants include basics like access to clean and safe water, healthy land and other resources that are required to ensure good health. Economic determinants are essential to many First Nations’ self-determination; the ability to make decisions over how to best manage resources on traditional territories is a fundamental determinant of health. The outermost circle represents the FNHA vision of “healthy, self-determining and vibrant B.C. First Nations Children, Families and Communities.” Within this circle are people holding hands to demonstrate togetherness, respect and relationships. Children, as the heart of communities, are included in the circle along with adults and Elders. There are gaps in the circle to signify that the circle is constantly changing; people may enter and leave, and the circle can grow and shrink over time, much like the cycles of life. B. LIFE CONTEXT The following section of this report includes analysis primarily for the life context of a smaller cohort of 82 young persons who died. For these 82 persons, additional data was available to the BCCS prior to the death review panel3. Information was accessed from BCCS investigative notes, MCFD case documentation and care plans. Of these 82 young people, 62 had been in care or on a youth agreement and an additional 20 had received extensive support services. Number of Years in Care Of the cohort of 82 youth and young adults, almost three quarters (n=62) had been in care (CCO, TCO, VCA or SNA) or on a Youth Agreement for multiple years. Of these 62:   53% had been in care or on youth agreements between 0-4 years; and, 47% had been in care or youth agreements for greater than five years. Additionally, of the remaining 20 youth who had received extensive services, 25% had been in care at some point during their life. Youth who have been in the child welfare system have a more challenging transition to adulthood than youth who were not in care. These challenges include: finding housing, completing education, finding employment, managing health or mental health issues or developing supportive relationships (Paulsen & Berg, 2016) (Jones, 2014). 3 See data limitations page 32 Page 17 Moves While in Care Of the 62 youth and young adults who were in care (CCO, TCO, VCA, or SNA) or on Youth Agreements4 at time of death or at age of majority:    Half (52%) of decedents had fewer than three moves during their total time in care; 27% of decedents had between four and 10 moves during their total time in care; and, 21% of decedents had more than 11 moves during their total time in care. Numerous placements or moves affect school attendance, the development of relationships and impact social supports (Stein, 2008). Youth who have fewer placements per year are almost twice as likely to complete high school before leaving care, are more likely to develop networks of support, receive coaching and develop life skills (Pecora, 2012). Social Determinants of Health Education Attainment Educational outcomes for the 82 decedents revealed that:     41% of the youth had less than Grade 12 education; 19% of youth were enrolled in or had completed Grade 12; 4% of youth were in college or attending a post-secondary technical training program (it is unknown if any of the older young adults, aged 20-25 years, were attending post-secondary schooling); and, Educational level was unknown (not documented) for 35% of youth who died. A recent Representative for Children and Youth (RCY) report found disparities in educational attainment. The report found that 51% of B.C. students in continuing care graduated within six years from the time they entered Grade 8 compared to 89% of all other students in the province. Of Indigenous students in continuing care, only 44% graduated within six years of beginning Grade 8 (RCY, 2017). Prospects for employment and financial independence are closely connected to academic achievement and skills training. Not completing a high school diploma is a significant predictor of future unemployment and poverty (Brownell, Roos, MacWilliam, Leclair, Ekuma, & Fransoo, 2010). Employment Of the cohort of 82 youth and young adults, file information indicated that:     4 24% were listed as students; 17% were employed (unskilled labour, service industry, food industry); 28% were unemployed; and, 30% employment was unknown. These young people had previously been in care. Page 18 Our findings are consistent with the literature. One study found that 30% of former foster youth were employed (Goodkind et al., 2011). Another review found that the United States, United Kingdom, Australia and Canada all have poor employment outcomes for former youth from care (Kovarikova, 2017). Many youth leave foster care without employment, are often employed in unskilled low-wage jobs, and are more likely to live in poverty than their non-foster youth peers (Jones, 2014). Housing Of the cohort of 82 young people, at the time of death:  67% (n=55) were housed;  28% (n=23) were not housed or had no fixed housing (couch surfing); and,  5% (n=4) housing was unknown.  There were 12 decedents who had a history of running away from their placement. For this cohort the risk of homelessness increased with age. At the time of death:  88% of 17-18 year olds who died were housed;  65% of 19 year olds who died were housed; and,  48% of 20-25 year olds who died were housed. The risk of homelessness is increased for youth who have aged out of care; youth are most vulnerable to homelessness in the first six months after aging out (Kovarikova, 2017). Page 19 Health and Well-being Family Contact In this cohort of youth and young adults who died:  43% had contact with family members;  12% did not have contact with family members; and,  Among 45% of decedents it was unknown if there was family contact. The BCCS is unable to conclude whether family contact would have been a positive or negative factor for the young persons who died. Youth leaving care may have limited social support from their own families, because of limited contact with their biological parents, or because many of the parents have challenges themselves (Paulsen et al., 2016). Parenthood Of the 82 young people in this cohort:  10 youth or young adults were pregnant or were parents of young children;  Six of the young persons who were pregnant or parenting were younger than 20 years of age; and,  Four of the decedents had children taken into care. Foster youth have higher rates of pregnancy than the general population, and pregnancies often occur shortly before or after discharge from foster care (Jones, 2014). Mental Health Of the cohort of 82 young people, investigative findings showed that 82% (n=67) had a reported mental health issue. Of these, 44% (n=36) experienced depression and 22% (n=18) experienced anxiety.  Of all 82 deaths, 39% (n=32) had past suicidal ideation, 27% (n=22) had attempted suicide and 26% (n=21) had a history of self-harm (e.g. cutting). Of the 82 young persons who died, 29 (35%) had behavioural health disorders (attention deficit hyperactive disorder, Fetal Alcohol Effect, Autism, Asperger Syndrome, and/or obsessive compulsive disorder). Mental health concerns were noted across all death classifications. This is especially correlated with suicides, accidental overdose deaths or deaths where illicit drugs contributed to the death. Almost all young persons who died by suicide had a mental health concern identified. “It is estimated that between 10% and 20% of Canadian children and youth may develop a mental disorder. If not identified, diagnosed and effectively treated, mental disorders with onset early in life can Page 20 lead to substantial negative health and social outcomes, including early mortality” (Canadian Institute for Health Information, 2015). Children who have been maltreated are more likely to develop emotional, behavioural and psychological problems. Long-term consequences for those who experience severe and prolonged maltreatment often include alcoholism, drug abuse, suicide and certain chronic diseases (RCY, 2015). Trauma In this review, many of the decedents had childhoods in which they were exposed to violence, problematic substance use and neglect. Most of these lives were touched by intergenerational trauma, as well as a history of significant personal trauma (history of neglect, abandonment, abuse, exposure to domestic violence, loss, or death of loved ones). “The effects of trauma can reverberate through individuals, families, communities and entire populations, resulting in a legacy of physical, psychological, and economic disparities that persist across generations” (National Collaborating Centre for Aboriginal Health, 2016). Fear or mistrust of services, lack of culturally relevant services, or lack of trauma informed practice may prevent young people from accessing services. Being supported by service providers who are knowledgeable in trauma-informed care and provide a culturally safe environment will increase the likelihood that young people feel safe when accessing supports and services. Substance Misuse During the period of this review, a total of 388 youth and young adults died from an illicit overdose in B.C., representing 25% of all deaths for this age group. Of these overdose deaths, 63 were aged 17-19 years and 325 were aged 20-25 years. Of the 200 deaths of youth transitioning from care or extensive supports and services, 94 (47%) deaths were related to illicit drug overdoses. Of these overdose deaths, 19 were aged 17-19 years and 75 were aged 20-25 years. Compared to the general population, the rate of overdose deaths is higher among youth and young adults transitioning from services. Among the cohort of 82 young people, 36 died by illicit overdoses. Of these, one-third of the decedents had been engaged in addictions programs (detox, rehabilitation, or drug and alcohol counselling services). Survey data indicate that more foster youth reported a problem with drugs or alcohol (a rate three to four times that of their peers) (Jones, 2014). Service Utilization and Stressors and Barriers This review found that more than half of the cohort of 82 decedents (58%) had identified stressors or barriers to accessing service. Some youth expressed fear about the future or concerns about transitioning to age 19, feeling overwhelmed, and several youth expressed dissatisfaction with their in Page 21 care experience and did not wish to engage further with supports. Some youth (n=18) were not ready to access services and/or declined supports or treatment offered. Two youth were waitlisted for programs or services and two were declined for supports as they did not meet eligibility. Two records indicated a lack of support or that there was no appropriate placement available. For those youth receiving supports and services, 43 were engaged with mental health teams, or counsellors. Of these, 29 had been seen by a psychiatrist or psychologist. We are aware of nine youth who were engaged with youth justice or probation services. The literature indicates that youth found it difficult to contact former program staff when that contact was formally ended, even when they had a good relationship with the staff person (Paulsen et al., 2016). To reduce service barriers for Indigenous people, it is imperative that services and programs are designed, developed and planned with local communities and with youth involvement, are culturally safe and that providers adhere to the practice of cultural humility, a core value of any work with Indigenous peoples. Page 22 PART 3: TRANSITION PLANNING Youth leaving care face many more challenges than their peers. They may lack a family support network, have limited or no financial resources, and often lack life-skills and have not completed school. They may suffer from low self-esteem and be scarred by trauma associated to violence, childhood neglect and/or abuse. Youth transitioning to adulthood need both informal and formal support, including social, emotional, financial and practical support. Happier, healthier, successful adults are typically embedded in meaningful relationships and communities and have extensive social support systems. Social support protects people against adversity though out their lives and is especially important during times of stress or change such as during the transition to adulthood (Paulsen et al., 2016). MCFD Children and Youth in Care Policies, Standards for Youth Support Services and Youth Agreements indicate the importance of beginning transition planning with youth as soon as possible, to increase the likelihood for successful emergence into adulthood and independence. This includes providing information about post-majority supports and services, information on how to apply, and assisting with applications for medical coverage, accessing financial support, and health and mental health services or other benefits. Although MCFD has formal policies around transition planning, it is essential to recognize the critical importance of early support for children throughout their development. This early support addressing health, mental health, culture and educational needs builds the foundational blocks on which successful transition to independence and adulthood are based. MCFD has several planning documents to support youth transition to adulthood. These include but are not limited to: Care Plans for children in care and a Plan for Independence for those on Youth Agreements, as well as formal transition protocols specific to children and youth experiencing mental health challenges. A Care Plan assesses the strengths and needs of a child in care across a set of domains:        Identity (including family and social relationships, culture and religion); Placement/living arrangement; Health; Legal; Education/social recreational activities; Self-care/ independence skills; and, Permanency plan. It outlines goals and actions to be taken to support the conditions that lead to the best possible outcomes. Care Plans are developed and reviewed on a regular basis. MCFD policy states that by the time a youth is 14 years old, preparation for independence should be well underway (BC Government, 2017). Page 23 Of the cohort of 82 young people, 62 decedents were required by policy to have a current Care Plan or Plan for Independence. Of the 62 young people:     36 (58%) had a completed and current Care Plan or Plan for Independence; 16 (26%) did not have a Care Plan or Plan for Independence; For six decedents it was unknown if either Plan existed; and An outdated Plan existed for four decedents. The BCCS reviewed the Care Plans or Plans for Independence to try to answer some specific questions related to transitioning to independence. Specifically did the plan identify: 1. Where the young person would live after reaching the age of majority and how they would fund their place of residence; what their income source to support their life needs would be; and what the young person would be doing in terms of employment, training or ongoing education. 2. How any identified health, mental health or substance-use needs would be addressed upon reaching the age of majority. 3. How cultural connections would be established, supported or maintained upon reaching the age of majority. It is possible that there were plans to answer these questions but they were not documented. Some of the plans reviewed in order to answer the above questions may have stated that the young person would get a job, go to school or address their substance issues when they were ready. That language reflected goals and did not provide sufficient information to answer the questions. Of the 62 decedents requiring a completed and current Care Plan or Plan for Independence:    Five (8%) included a plan related to achieving goals related to accommodation/ financial assistance or income/employment and education upon reaching the age of majority; Eight (13%) outlined a plan for meeting required health, mental health supports or services upon reaching the age of majority; and, Six included actions to address goals for maintaining cultural contact. Transition from care poses additional challenges among Indigenous young people due to the effects of historical trauma, colonization, and cultural dislocation. “Without ensuring that each young person has a clear plan in place for him or her to move into adulthood, and without providing these young people with the necessary supports, we are further perpetuating cycles of poverty” (Grand Chief Ed John, 2016). With respect to the 35 Indigenous youth and young adults required by policy to have a current Care Plan or Plan for Independence:  Two (6%) included a plan for achieving goals related to accommodation/financial assistance or income/employment and education upon reaching the age of majority; Page 24   Three (9%) outlined a plan for meeting required health, mental health supports or services upon reaching the age of majority; and, Five (14%) included actions to address goals for maintaining cultural contact upon reaching the age of majority. Adequate documentation supports provision of appropriate services, addresses the organization’s accountability requirement and complies with legal requirements (BC Government, January 2016). “These plans should be developed with the support and direct involvement of an Indigenous youth’s community” (Grand Chief Ed John, 2016). Page 25 PART 4: SPECIALIZED INVESTIGATIONS Following a coroner’s investigation, recommendations may be put forward to the chief coroner for consideration. These recommendations address systemic issues with policies and practices and are intended to prevent deaths in similar circumstances. Of the 200 deaths reviewed including Inquests, there were 42 Coroner or Jury recommendations related to 13 deaths of youth transitioning from care or extensive services. These included nine recommendations to either the Representative for Children and Youth or the MCFD:   That the Representative for Children and Youth considers reviewing the government services provided to the decedent with a view to improving services and outcomes for children in the Province of British Columbia; and, That the Ministry of Children and Family Development consider conducting a comprehensive review of the services provided to the decedent with a view to improving services and outcomes for children in the Province of British Columbia. Page 26 PART 5: RECOMMENDATIONS This death review panel has developed a set of recommendations considering the current research and applying this knowledge to youth in transition investigative findings. The recommendations arising from the death review panel were developed in a manner that was:       Collaborative; Attributable to the deaths being reviewed; Focused on identifying opportunities for improving public safety and prevention of future deaths; Targeted to specific parties; Realistically and reasonably implementable; and, Measurable. The overall findings of this review indicated:       A lack of documented transition planning for youth leaving care or on youth agreements; A disproportionate number of Indigenous young people died; High rates of suicide and drug overdose deaths; High rates of health and mental health issues; Lower completion of educational attainment; and, Barriers (system and personal) to successful transition to independence. The panel identified four key areas to reduce the deaths:     Extending service supports based on the young person’s needs; Improved communication between service providers with the goal to increase engagement of youth; Engage with youth on service planning and policy development; and, Monitor outcomes and use findings to support service planning and policy changes. Reducing barriers and increasing access to services based on need The transition from adolescence to adulthood is a significant stage of development - physically, socially and emotionally. Most young people are not fully prepared for self-sufficiency. Most young people continue to receive financial and social support and guidance from their parents well into young adulthood, and they remain interdependent with their social support rather than independent. When youth in care or on Youth Agreements reach their 19th birthday, they face many more challenges than their peers. Most youth leaving care do not have the financial, medical or social support tools to successfully transition to independence. They often lack a family support network, a connection to their community and culture, have limited or no financial resources, lack life-skills and have not completed school. Page 27 Many youth leaving government care lack relationships that act like a safety net. For many young adults, there is no longer a case manager overseeing or assisting with coordinating support or services. Instead these vulnerable young adults must maintain housing, complete their education, find employment, manage health or mental health issues, or develop new supportive relationships. They leave their social worker, their youth worker, their foster family or other support persons with whom they may have formed trusted relationships. These relationships by virtue of leaving care are severed. The MCFD provides some extended support to qualifying youth through an Agreement with Young Adults (AYAs). In its current state, many young people leaving care either do not qualify for or are unaware of AYA supports. As well, although a variety of frontline staff can complete an assessment for AYA eligibility, frontline staff who have developed working relationships with the youth typically do not administer the AYA program. Instead, AYA administration is primarily a financial transaction; missing the local, in-person contact and supportive connections. Persons accessing AYA supports need to complete one of the following requirements:     60% course load in an educational or skills training program (40% if you have a permanent disability) A minimum of 15 hours a week participation in a rehabilitation program A combination of educational / skills training and rehabilitation program time that equals at least 15 hours a week An approved life skills program that is at least 12 hours a week (or 48 hours per month) Youth leaving care or transitioning from Youth Agreements may not yet be ready to fully meet the administrative requirements of AYAs. Many are still dealing with past trauma, mental health challenges or life issues and need additional flexibility for meeting AYA requirements. Some youth who have left care may not be emotionally able to reach out to former program staff for advice or guidance, even if they had a good relationship with that person. Some may lack trust in the system and may not yet be able to re-engage with supports. Fear or mistrust of services, lack of culturally relevant services, or lack of trauma informed practice may prevent young people from accessing services. Being supported by service providers who are knowledgeable in trauma-informed care and provide a culturally safe environment will increase the likelihood that young people feel safe when accessing supports and services. Previous death review panel reports have made recommendations around the need to consult with youth about how to reduce barriers to services and ensure programs are relevant, and culturally safe for young people. Page 28 Recommendations #1: Expand Agreements with Young Adults (AYAs) to Address Self-identified Transition Needs  By April 2019, the MCFD will consult with youth, and additionally Delegated Aboriginal Agencies and frontline staff about how best to administer AYAs (e.g. youth needs for ongoing supports, ease of accessibility).  By October 2019, the MCFD will amend the qualifying criteria for AYAs so that all young people transitioning from care or Youth Agreements are universally eligible for the program. Services and financial support provided will address unique circumstances and transition needs of the young person. Strengthening transition planning and collaborative case management, service coordination The literature finds that good preparation for leaving care results in better outcomes and coping after leaving care (Mendes et al., 2011). The literature also identifies that transition planning needs to begin early and should be based on the individual’s needs and include ongoing support. This review found that many of the young people who died had childhoods in which they were exposed to violence, addictions and neglect. Many of these lives were touched by intergenerational trauma, effects of colonization, as well as a history of significant personal trauma (history of neglect, abandonment, abuse, exposure to domestic violence, loss, and/or death of loved ones). A high proportion of youth in this review had a mental health condition and/or used illicit substances. There is a need for greater access to trauma informed, culturally safe mental health and addiction services for young people. Young people with additional needs (e.g. disability, developmental delays, mental health issues, young parents) need extra assistance or programs to support them. Schools are an integral partner for supporting the academic achievement and successful transitions to adulthood for vulnerable young people. This review found that a minority of the young persons who died were enrolled in or had completed Grade 12 and very few had entered post-secondary training. Transition planning is key to support youth success, it should begin early with collaborative planning amongst all service providers to ensure ongoing health, mental health and education needs are addressed early. As well, youth transitioning from care and into adulthood need strong, stable, social supports to help protect them during times of stress and transition. For youth who cannot rely on family for support, a caring adult is protective for youth at risk (Paulsen et al., 2016). Page 29 Recommendation #2: Ensure Collaboration to Support Effective Planning and Service Provision  By April 2019, MCFD in collaboration with Indigenous and other stakeholders (health, mental health, police, education, community service providers) will develop processes or protocols to improve ongoing information sharing to better meet the planning and support needs of youth in care.  By April 2019, the MCFD will consult with youth and Indigenous partners on an ongoing basis to identify needs and services that would assist young people to successfully transition to adulthood.  By October 2019, the Ministry of Education will ensure that all children in care have a plan to support their educational needs.  By December 2019 the Ministry of Mental Health and Addictions will collaborate with MCFD, Health and First Nations Health Authority to ensure access to youth mental health and addictions services for youth transitioning from care or on Youth Agreements. Monitoring outcomes Multiple agencies and ministries may be involved in independence planning and/or working with youth transitioning from care to adulthood. In order to assess the effectiveness and efficiencies of supports, programs and services, those services need to be evaluated on an ongoing basis. This review found that decedent’s case-files lacked documentation to effectively demonstrate planning for independence. Currently there is no process for monitoring outcomes of former children in care or those previously on Youth Agreements or those on Agreements with Young Adults. Recommendation #3: Monitor Support Service Effectiveness for Youth Leaving Care  By April 2019, the MCFD will consult with young people in care, formerly in care, or on Youth Agreements and Indigenous partners to develop transition and AYA outcome indicators.  By October 2019, the MCFD will develop a plan to monitor and evaluate transition planning and outcomes and AYA outcomes. Page 30 DATA LIMITATIONS AND CONFIDENTIALITY This review identified a number of data limitations and issues, including:  The BCCS operates in a live database environment. The data presented within this review is based on open and closed BCCS investigative files. It includes analysis of BCCS investigative notes, medical records and other documents collected or protocols completed during the course of the coroners’ investigation. Some deaths were still under investigation and the information was incomplete.  The BCCS obtained late access to MCFD data for closed BCCS death investigations of young adults aged 20-25 years. This was due to clarifying legislative authorities for access to closed file information on young adults. A preliminary review of the new MCFD information revealed that an additional 118 decedents should be included in this case-review cohort. However, given the timeliness of receiving MCFD confirmation of service involvement, there was insufficient time to analyze the decedent’s life factors in detail. Thus, this case-review analysis is primarily based on the 82 deaths of youth and young adults age 17-25 years where data was available prior to November 22, 2017. Preliminary analysis of the new MCFD dataset indicates that the same transition challenges exist for the 118 decedents.  As of June 1, 2016, the BC Coroners Service implemented the Aboriginal Administrative Data Standard; this will improve data quality and completeness of Indigenous identity on BCCS investigative files. Prior to June 2016, there was the potential to under-report deaths based on First Nations identity. Past BCCS data collection resulted in limited or absent information about Indigenous identity (i.e., First Nations, Métis, Inuit), or whether an individual lived on a reserve.  This review presents data subsets with small numbers (n). These should be interpreted with caution. When the ‘n’ is low, conclusions are less certain than for larger groups.  Provisions under the Coroners Act and Freedom of Information and Protection of Privacy Act allow for the BCCS to disclose information to meet its legislative mandate and support the findings and recommendations generated by the review process. For the purposes of this report, information is presented in aggregate. Details that could identify the people have been omitted to respect the privacy of the person who died and their families. The BCCS is sensitive to the privacy of individuals and families that it serves and proceeds with caution when reporting review findings. Page 31 APPENDIX A – DATA TABLES MCFD data for the period of 2011-2016 found that there were:  9,734 youth in care (CCO, TCO, VCA, SNA, or AFP) at ages 17 and 18;  3,705 youth in care (CCO, TCO, VCA, SNA, or AFP) in the month before their 19th birthday;  4,924 youth age 17-18 years who received support services (YAG & SSY); and,  2,068 youth receiving AYA payments. And:  In 2016, there were 444 youth who received support services (YAG & SSY) in the month before their 19th birthday. Page 32 APPENDIX B – MCFD SERVICE DESCRIPTION Overview of MCFD Youth Transitional Support Services and Youth Agreements Youth Transitional Support Services and Agreements provide a continuum of youth services available under Part 2.1 of the Child, Family and Community Service Act (CFCSA) for both “youth” 16 to 19 years of age and post-majority supports to “young adults” aged 19 and up to 26 years of age. Services engage youth in:         understanding risky situations and making positive, safe changes in their lives; improving relationships with friends and family; finishing or continuing education, gaining skills and education to secure employment; learning to manage emotions and behaviour; exiting the street, and finding shelter and a home; connecting to services to address health, additions and well-being; learning to manage money and households; and, making successful transitions to adulthood and independence. Youth Transitional and Post Majority Services For youth (aged 16 up to their 19th birthday) and young adults (aged 19 up to their 26th birthday) transitioning out of government care or Youth Agreements, housing, education and training, life-skills, employment, finances and ongoing support are all part of the planning focus. Support and assistance are provided for youth who require support with daily living, health and safety, financial, educational and other needs. Youth Transitional Services help young people make healthy changes in their lives, improve important relationships and strengthen connections with friends and family, find housing, finish or continue their education, acquire skills and education for better employment opportunities, and, where appropriate, obtain mental health support or drug and alcohol counselling. Post-majority supports include:   Agreements with Young Adults (S 12.3 of the CFCSA) which provide support and financial assistance to young adults aged 19 up to 26 years of age formerly in care or on a Youth Agreement. The Agreement with Young Adults allows youth to upgrade their education or take part in rehabilitative programs such as mental health or addictions counselling; and, Youth Education Assistance Fund which provides bursaries to former youth in continuing care to pursue vocational training and post-secondary education. As well, a pilot program in Greater Vancouver, the YM/YWCA STRIVE Program, provides support to young adults (aged 17-24 years) transitioning or have transitioned out of foster care to gain life and work skills they need to become independent. Other available post majority supports include: Page 33     Provincial Tuition Waiver Program: This program waives tuition for eligible young adults who had been in care for a cumulative total of at least 24 months; Laptops for Learning: A pilot project where the MCFD partnered with IBM Canada and the Ministry of Citizens’ Services to provide free laptop computers to a target population of 369 young adults from government care currently receiving funding under the AYA program; Keeping Young Adults Connected: A two-year pilot project starting in spring 2017 where MCFD partnered with TELUS through the Strategic Investment Fund to offer up to 1,000 free phones and data plans for young adults on AYA; and, AgedOut.com: An innovative, engaging website that uses interactive learning modules, realtime chat and text-to-speech technology to provide young adults with resources and information they need to successfully transition to adulthood. Page 34 GLOSSARY Aboriginal: A collective term used to describe the three constitutionally recognized Indigenous populations in Canada – First Nations ('Status Indians'), Métis and Inuit. While the term Aboriginal is commonly accepted, identifying each of these populations specifically by name is preferable where appropriate. Age of majority: Means 19 years of age. Agreements with Young Adults (AYAs) (s. 12.3, CFCSA): Provide support and financial assistance to young adults, aged 19 up to 26 years, formerly in care (Continuing Custody Order) or on a Youth Agreement. The Agreement with Young Adults allows youth to upgrade their education or take part in rehabilitative programs such as mental health or addictions counselling. Continuing Care: Refers to children and youth who have a continuing custody order (CCO) that makes the director under the Child, Family and Community Service Act (CFCS Act) the sole personal guardian. This term also includes children and youth under the director’s ongoing care pursuant to Section 51 of the Infants Act and Section 24 of the Adoption Act. None of the deceased in this review were in care pursuant to the Infants Act or Adoption Act. Continuing Custody Order (CCO): An order under the CFCSA placing a child in the continuing custody of a director. Delegated Aboriginal Agencies (DAAs): The Ministry of Children and Family Development has agreements between the province and First Nations communities to return historic responsibilities for child protection and family support to Aboriginal communities. These agreements are known as delegation agreements. Through delegation agreements, the Provincial Director of Child Welfare (the Director) gives authority to Aboriginal agencies, and their employees, to undertake administration of all or parts of the Child, Family and Community Service Act. The amount of responsibility undertaken by each agency is the result of negotiations between the ministry and the Aboriginal community served by the agency, and the level of delegation provided by the Director. https://www2.gov.bc.ca/gov/content/family-social-supports/data-monitoring-qualityassurance/reporting-monitoring/accountability/delegated-aboriginal-agencies Dogwood Certificate or Evergreen Certificate: See definition online at: http://www.bced.gov.bc.ca/reporting/glossary.php?initLetter=All#bcscc First Nations: The term ‘First Nations’ has largely become the preferred terminology for Indigenous peoples of North America in what is now Canada, and their descendants, who are neither Métis or Inuit. First Nations people may be ‘Status’ (registered) or ‘non-Status’ as defined under the Indian Act. In Care: For this review, includes those youth and young adults who at age of death or at age of majority had a legal designation of CCO, TCO, VCA or SNA. Page 35 Indigenous: Is most frequently used in an international or global context and is referred to by the United Nations broadly as ‘peoples of long settlement and connection to specific lands who have been adversely affected by incursions by industrial economies, displacement, and settlement of their traditional territories by others’. Similarly the term can also refer to groups of peoples or ethnic groups with historical ties a territory prior to colonization or formation of a nation state. Typically, Indigenous peoples have preserved a degree of cultural and political separation from the mainstream culture and political system of the nation state within the border of which the Indigenous group is located. Extensive Services: For the purposes of this review, includes those youth and young adults who at age of death or at age of majority had received extensive support services such as Child Youth Mental Health (CYMH), Child Protection (CP), Family Service (FS), Child and Youth Special Needs (CYSN) or Youth Justice, or who had previously been in care. Non-Ministry Involved: Youth or young adults who had no MCFD service history or minimal MCFD service history. Ministry: Means Ministry of Children and Family Development Special Needs Agreements (SNA): For children with special needs requiring specialized services outside the family home. The social worker will consider a Special Needs Agreement with the parent(s) and child over the age of 12 years when:    The agency has the required resources (e.g., financial, assessment, health, therapeutic, dietary) to meet the special needs of the child; It is in the best interests of the child; or, The agreement meets the child’s need for safety, security, stability and continuity of relationships. Eligibility is confirmed through an assessment completed by a qualified professional in the area of child development, such as a: psychologist; psychiatrist; physician or pediatrician; psychiatric nurse, mental health or infant development worker; special education teacher; or other health-care professional who has knowledge of or has recently assessed the child. The Special Needs Agreement provides a coordinated program of interventions designed to meet the needs of the child and will involve an interdisciplinary team. Support Services for Youth (SSY) (S 12.1, CFCSA): For at-risk and high-risk youth who are absent from their families and in circumstances that endanger their health, safety and well-being. Services include street- and facility-based outreach services, reconnect services, and shelter services. Services focus on connecting with youth to assess their capacities, risks and needs, and with developing an immediate needs and safety plan that meets their basic needs and provides interim safety. Possible outcomes of services at this stage are: a supported return home to family and community, or an interim supports and assessment to determine the best longer-term service plan if youth cannot return home, including: Page 36 living with extended family (e.g. Extended Family Program Agreement). Youth may access services in the following ways:       Connections made through outreach or community services; A child-protection referral; Walk-in to a ministry or agency office; Transition from Care into a Youth Service response; Entering into a Youth Agreement; or, Coming into Ministry care. Temporary Custody Orders (TCO): An order under the CFCSA placing a child for a specified period in the custody of a director or another person, and includes any extension of or change to that order. Voluntary Care Agreements (VCA): A written agreement with a parent who has custody of a child and is temporarily unable to look after the child in the home in which the parent may give the care of the child to the director and delegate to the director as much of the parent's authority as the child's guardian as is required to give effect to the agreement. Youth Agreements (YAG) (S. 12.2, CFCSA): An out-of-care alternative to foster- or group-care for youth (aged 16 to 18 years) in need of assistance and who cannot return to live with family or extended family. Youth must demonstrate willingness to enter into an agreement with the Ministry and have the capacity to successfully engage in the agreement.   Youth in Youth Agreements are typically characterized as being “high risk,” in that they have significant adverse conditions in their lives and/or are in situations that would otherwise cause them to be in need of protection. Adverse conditions include homelessness, victim of sexual exploitation, mental health and/or substance use challenges, and other barriers to healthy development to adulthood and independence. Through a Plan for Independence, a Youth Agreement can provide residential, educational or other support services, and financial assistance, while supporting the youth’s safety and wellbeing through one-to-one support works and/or group life skills programs. Page 37 REFERENCES AND BIBLIOGRAPHY BC Coroners Service (2013). B.C. Coroners Service Death Review Panel: A review of Child and Youth Suicides 2008-2012 https://www2.gov.bc.ca/gov/content/safety/public-safety/deathinvestigation/child-death-review/reports-publications BC Coroners Service (2017). B.C. Coroners Service and First Nations Health Authority Death Review Panel: A review of First Nations Youth and Young Adult Injury Deaths 2010-2015. https://www2.gov.bc.ca/gov/content/safety/public-safety/death-investigation/child-deathreview/reports-publications BC Coroners Service (2017). Preventing death after overdose: B.C. Coroners Service Death Review Panel. A review of overdose deaths in youth and young adults 2009-2013. http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/deathinvestigation/child-death-review-unit/reports-publications/overdose-death-youth-youngadult.pdf BC Government (January 2016). Standards for Youth Support Services and Youth Agreements. BC Government (June 2017). Children and Youth in Care Policies. Child Welfare Policy. BC Representative for Children and Youth (2014). On their own: Examining the needs of BC youth as they leave government care. https://www.rcybc.ca/sites/default/files/documents/pdf/reports_publications/rcy_on_their_ow n.pdf BC Representative for Children and Youth (2015). Paige’s story: Abuse indifference and a young life discarded. https://www.rcybc.ca/sites/default/files/documents/pdf/reports_publications/rcypg-report-final.pdf BC Representative for Children and Youth (2017). Room for improvement: Towards better education outcomes for children in care. http://www.rcybc.ca/sites/default/files/documents/pdf/reports_publications/summaryfinal.pdf Brownell, M. D., Roos, N. P., MacWilliam, L., Leclair, L., Ekuma, O., & Fransoo, R. (2010). Academic and social outcomes for high-risk youths in Manitoba. Canadian Journal of Education, 33(4), 804-836. Canadian Institute for Health Information (May 2015). Care for children and youth with mental disorders. https://secure.cihi.ca/free_products/CIHI%20CYMH%20Final%20for%20pubs_EN_web.pdf Johns, Ed, Grand Chief (2016). Indigenous resilience connectedness and reunification from root causes to root solutions. http://fns.bc.ca/wp-content/uploads/2017/01/Final-Report-of-Grand-ChiefEd-John-re-Indig-Child-Welfare-in-BC-November-2016.pdf Page 38 Fowler, P. J., Marcal K.E., Zhang J., Day, O., & Landsverk, J. (2017). Homelessness and aging out of foster care: A national comparison of child welfare-involved adolescents. Children and Youth Services Review, 77, 27-32. Greenwood, M. (2015) National Collaborating Centre for Aboriginal Health. https://www.ccnsanccah.ca/28/Determinants.nccah Goodkind, S., Schelbe, L.A., & Shook, J. (2011). Why youth leave care: Understanding of adulthood and transition successes and challenges among youth aging out of child welfare. Children and Youth Services Review, 33, 1039-1048. Jones, L.P. (2014). The role of social support in the transition from foster care to emerging adulthood. Journal of Family Social Work, 17, 81-96. Kang-Yi, C.D., & Adams, D.R. (2015). Youth with behavioural health disorders aging out of foster care: A systematic review and implications for policy, research, and practice. Journal of Behavioural Health Services and Research, 25-51. Kovarikova, J. (2017). Exploring youth outcomes after aging-out of care. Office of the Provincial Advocate for Children and Youth. Mendes, P., Johnson, G., & Moslehuddin, B. (2011). Young people leaving state out-of-home care: Australian policy and practice. North Melbourne: Australian Scholarly Publishing. National Collaborating Centre for Aboriginal Health (2016). Aboriginal peoples and historic trauma. https://www.ccnsa-nccah.ca/430/Aboriginal_Peoples_and_Historic_Trauma.nccah Paulsen, V., & Berg, B. (2016). Social support and interdependency in transition to adulthood from child welfare services. Child and Youth Services Review, 68, 125-131. Pecora, P.J. (2012). Maximizing educational achievement of youth in foster care and alumni: Factors associated with success. Children and Youth Services Review, 34, 1121-1129. Plecas, B. (2015). Plecas review, part 1: Decision time. http://www2.gov.bc.ca/assets/gov/family-and-social-supports/services-supports-for-parentswith-young-children/reporting-monitoring/00-public-ministry-reports/plecas-report-partone.pdf and Youth Health and Well-Being Indicators Project Page 39 Provincial Health Officer of British Columbia (2007). Joint Special Report Health and Well-Being of Children in Care in British Columbia: Educational Experiences and Outcomes. https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-theprovincial-health-officer/reports-publications/special-reports/joint_special_report.pdf Provincial Health Officer of British Columbia (2013). Child and youth health and well-being indicators project: CIHI and B.C. PHO joint summary report, p8. https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-theprovincial-health-officer/reports-publications/special-reports/child-health-2013.pdf Stein, M. (2008). Resilience and young people leaving care. Child Care in Practice, 14(1), 35-44. Tourand, J., Smith, A., Poon, C., Saewyc, E., & McCreary Centre Society (2016). Raven’s Children IV: Aboriginal youth health in BC. Vancouver, BC: McCreary Centre Society. Tweddle, A. (2005). Youth leaving care: How do they fare? Briefing paper. Prepared for the Modernizing Income Security for Working Age Adults. Wiens, M. (2014). Early Childhood Development (ECD) Literature Review. School of Population and Public Health, University of British Columbia. http://earlylearning.ubc.ca/media/publications/library_page_updates_2016/1.0_ecd_lit_rev_m ain_document_2014_08_13.pdf Page 40