New Brunswick’s auditor general has flagged a number of issues with the province’s child death review process.
Several key legislative requirements for child death reviews are not being met, Paul Martin said in his report on Tuesday.
“The loss of a child is a profound tragedy and impacts families and communities,” the auditor general said during his presentation in the legislature.
“In the wake of such an event, it is crucial that every aspect of the investigation, inquest and subsequent Child Death Review Committee review is conducted with the utmost diligence and integrity.”
Key specific findings in Martin’s report concluded that investigations, inquests and reviews are not always completed in a timely manner.
Martin said the average time it took to complete a child death investigation was 300 days in 2022 and 250 days in 2023.
“The department has not established expected timelines to complete an investigation, citing the time it takes to receive autopsy or police reports as a major factor in the delay,” he said.
Of the 53 completed child death investigations during the two-year audit period, 46 had autopsy or police reports, which took an average of 226 days to receive.
Around three-quarters of all child death investigations that were completed took more than 100 days to receive reports, with one taking more than 500 days.
Martin’s audit also found that 28 per cent of the death investigations did not have evidence of an autopsy, even though it is required in department policies.
Three deaths were recommended to undergo an inquest during the audit period. One was already done at the time of the audit and another was completed subsequent to the office’s field work.
“A coroner made a declaration to hold the third inquest, but the decision was overturned by the chief coroner with no documented rationale for having done so,” said Martin.
Martin said the department also has no established expected timeline for initiating and completing an inquest. One inquest took more than 990 days from the date of death while another took 935 days, his report noted.
The watchdog also found that Child Death Review Committee recommendations made to mitigate future risks of child deaths are not always being shared with relevant departments, organizations or agencies.
In addition, of the 39 child death reviews completed during the audit period, only 26 reports were produced. Legislation requires the committee to submit a report to the chief coroner within 120 days of commencing a review.
“The value in the committee’s work is in advising the chief coroner on matters to improve safety and prevent the occurrence of unnecessary child deaths. Timely provision of recommendations to relevant organizations is critical in mitigating such risks,” said Martin.
The auditor general made 28 recommendations to the Department of Justice and Public Safety.
