N.B. child death review process isn't following the law, says watchdog
Auditor general flags failure to meet legislated requirements to review, report on child deaths
New Brunswick's auditor general says the province is failing to meet its legal obligations in reviewing and reporting on child deaths.
Auditor general Paul Martin found the child death review committee, whose job is to review and report on deaths of those 18 and under, is not always meeting that mandate.
The committee reviews all child deaths reported to the coroner's office in order to examine the circumstances of a child's death and "with the intent to prevent future deaths and improve the health, safety and well-being of all children in New Brunswick," says the report.
The committee is also tasked with reviewing deaths of children in the province's care, or who had received child welfare services in the year leading up to a death.
Martin said failing to follow the legislated process creates the potential for tragic consequences.
"The whole intention of these recommendations that come from the child-death review committee is to prevent another child's death," he said, speaking with reporters at the legislature.
"If those recommendations aren't getting to the people responsible, to the departments, to those that oversee these matters, there's potentially another child's death that could have been prevented that was not. That can't continue."
Martin's office found no evidence of any committee review for 32 child death cases recorded in 2022 and 2023, according to his newest report, which was released on Tuesday.
It also found the committee has failed to meet its obligation to submit reports to the chief coroner for every child death review. During the audit, the report says the committee held 39 child death reviews but only completed 26 reports.
"For child deaths reviewed by the CDRC where no report has been written, there are meeting minutes confirming a review took place but there is no documented rationale or explanation why recommendations were not required," the report says.
When the committee made recommendations based on a review, the report found those recommendations were not given to the departments with authority to act on them — a requirement under the Coroner's Act.
Martin also found that public reporting on results was "incomplete and not timely," with just two of 20 recommendations issued during the audit period made public.
"In recent years, the public reporting of the child death review committee has been limited," the report says. "Given its critical role, it is imperative to ensure that its processes and practices are robust, transparent and effective."
Martin said it's unclear from his investigation why the process isn't being followed. He added that it will be important for the department to speak to that question when it comes before a legislature committee at a later date.
Martin's report also flags issues with coroner investigations, coroner training and record-keeping after an inquest.
It says coroner investigations into child deaths took 2½ times longer than investigations into adult deaths — 249 days on average for children, compared to 100 days for adults, between April 2022 and June 2024.
Public Safety Minister Robert Gauvin didn't have an answer as to why the process is falling short but said he plans to act on all 28 recommendations issued by the auditor general.
"This is not a good day for the Department of Public Safety, but we have the team in place to fix it all," he said. "We need to have more transparency going forward and make sure we have the proper persons in place."
Gauvin said 15 of the 28 recommendations will be completed by the end of the year and all but one will be addressed before the end of March.
The final one, a recommendation to improve policies, training and equipment, will be completed by September 2025, he said.
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