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Accountability

Case Review Summary Reports

Ministry practice standards require that a designated director be notified immediately regarding the death or critical injury of a child in care or a child who has received ministry services across program areas in the 12 months previous to the death or critical injury.

These notifications provide the Director with the opportunity to objectively review the circumstances, receive feedback, and learn from these incidents. The Director may seek additional or clarifying information regarding the circumstances. Depending on the responses, the Director may be satisfied that there are no outstanding issues or questions. This is often the case for natural, expected deaths where there is no reason to believe that practice had an impact on the outcome for the child. Otherwise, the Director may decide a case review is required.

The decision to conduct a case review is made no later than 20 working days following the incident and is generally made at the regional level by the Director of Quality Assurance. The decision is based on a review of the death or critical injury 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. The decision regarding the specific type of case review is based on the nature of the ministry’s involvement and how questions related to past involvement can best be examined.

All case reviews include development of a background of the family’s involvement with the ministry or other service provider, a chronology of events, an analysis/discussion of the information, and a written report. All case reviews may result in recommendations to address issues that have been identified. The recommendations are tracked and monitored for implementation by the regional Director of Quality Assurance. It is a regional responsibility to complete the recommendations and provide supporting documentation to the provincial Quality Assurance Coordination and Support (QACS) Branch. The QACS Branch enters, updates, and closes recommendations in the Integrated Practice Analysis Tracking (IPAT) provincial database and, when necessary, follows up with the respective regions regarding the status of recommendations.

There are five types of case reviews with different methodologies: a file review, an integrated file review, a comprehensive review, an integrated comprehensive review, and a joint review:

  • A file review (FR) consists of an examination of relevant case files and electronic records. Informal conversations with staff may occur; no formal interviews are conducted. A FR is more limited in scope than a comprehensive review. If further information is needed for a more in-depth understanding of the case, a FR can be changed to a comprehensive review. A FR is to be completed within 6 months of the decision to conduct a case review.
  • An integrated file review (IFR) consists of an examination of relevant case files and electronic records from more than one program area or region. Informal conversations with staff may occur; no formal interviews are conducted. An IFR is to be completed within 6 months of the decision to conduct a case review.
  • A comprehensive review (CR) includes an examination of relevant case files and electronic records, the development of terms of reference, and staff and other stakeholder interviews. A CR is to be completed within 11 months of the decision to conduct a case review. However, a CR cannot be conducted until after an ongoing criminal investigation and any ensuing court proceedings are completed.
  • An integrated comprehensive review (ICR) includes an examination of relevant case files and electronic records from more than one program area or region, the development of terms of reference, and staff and other stakeholder interviews. An ICR is to be completed within 11 months of the decision to conduct a case review. As with a CR, an ICR cannot be conducted until after the completion of a criminal investigation and court proceedings.
  • A joint review (JR) is an examination where more than one director under the CFCSA was involved in serving the family, including incidents involving delegated Aboriginal agencies. A joint review utilizes the methodologies and timelines of any of the file or comprehensive reviews as outlined above and as appropriate.

The BC Children and Youth Review conducted by Judge Hughes recommended the ministry publicly release a summary of each child fatality review report every six months. As of June 2011, the Ministry revised its process for posting summaries to include all fatality and critical injury case reviews twice yearly. The public disclosure of summary reports is subject to a similar process as Freedom of Information requests received by Citizens’ Services. The case review summary reports 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.

The ministry responds to approximately 30,000 child protection reports each year. There is a need for critical self-analysis within the organization to ensure that standards are met and that areas for improvement are identified and addressed. The case review process, along with other quality assurance functions, demonstrates the ministry's ability to build on its strengths, analyze its practices, and ensure continuing improvements to the way services are delivered to the many children and families served every day.

Future Direction

The Ministry intends to improve the response to individual case reviews by identifying areas for improvement and commencing action on those areas requiring improvement within 90 days of finalizing a case review. 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 review through aggregate analysis.

Case Review Summary Reports

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