The parents of a London teen who died while waiting for mental health treatment in Ontario’s child protection system are calling on the coroner to launch an inquest into her death.
Children’s aid societies have housed hundreds of kids, including many with mental health conditions and high-risk behaviours, in unlicensed settings.
Children’s aid societies have housed hundreds of kids, including many with mental health conditions and high-risk behaviours, in unlicensed settings.
Fifteen-year-old Jade spent a year living in budget motels because child protection workers couldn’t find an appropriate placement for her, a Star investigation found. During that time, she ran away repeatedly, lived on the streets and developed a serious drug addiction. She died of a fentanyl overdose in October 2024.
“We don’t want other families to go through what we’ve been through,” Jade’s father, Tim, said in an interview. Jade’s parents and child advocates say an inquest is needed to learn how the province failed to protect her and to prevent other children from falling through the cracks.
(To comply with a court-ordered publication ban under the Youth Criminal Justice Act, the Star has used middle names for Jade and her family members.)
Diagnosed with several mental health and developmental conditions, Jade became a ward of the province after her adoptive parents, and then her birth mother, relinquished custody to the Children’s Aid Society of London and Middlesex because they could no longer manage her needs and behaviours at home.
An increasing number of families are surrendering their kids to CAS for this reason, a disturbing trend documented in reports to the provincial ombudsman that have risen since the COVID-19 pandemic. Child welfare agencies have been warning the government about a critical shortage of services and supports for children with complex needs for at least four years, the Star has found.
Nearly nine months after Jade ran away from the hotel she’d been living in and died of a fentanyl overdose, the province hasn’t started any of the reviews that are meant to take place after a child dies while in the care of the children’s aid society. London CAS said it’s prohibited from commenting on individual cases but the agency is committed to participating in investigations that could lead to improvements in child welfare.
Since her death, the London CAS has housed nine more kids in hotels. The agency says it is forced to use hotels as a last-resort measure when child protection workers are unable to find appropriate treatment or housing.
A public coroner’s inquest is not mandatory in cases like Jade’s, which are instead investigated by a child death review committee whose reports are not made public. A spokesperson for the Office of the Chief Coroner of Ontario, Dr. Dirk Huyer, confirmed they are considering a request from the family for a discretionary inquest.
“(Jade) would want this,” Mona, her adoptive mother, said in an interview. “She would want to help other children like her.”
Earlier this month, Tim made a personal appeal to Premier Doug Ford for help.
“Changes need to be made,” Tim wrote in a text message to Ford’s personal cellphone number, which the premier shares with the public. He asked Ford to read the story about Jade. “Just imagine that it was your daughter,” he wrote. Ford replied, and they had a brief phone call in which Tim said the premier promised to read the Star’s investigation. Tim said he felt encouraged by the conversation.
The Children’s Aid Society of London & Middlesex said it still relies on hotels because it has no other options, the result of “chronic
The Children’s Aid Society of London & Middlesex said it still relies on hotels because it has no other options, the result of “chronic
Through his press secretary, Ford declined an interview request from the Star. In a statement, his office said: “Our heart goes out to Jade’s family. Her father shared what an incredible young woman she was and what an incredible loss this has been to their family. The death of any child is absolutely heartbreaking.”
It is the expectation of the premier’s office “that anyone who needs mental health and other support services can access them in a timely manner,” the statement said.
The premier’s press secretary did not say whether Ford supports the family’s call for an inquest or whether he would direct the ministries responsible for child death reviews to start them.
Michael Parsa, the minister responsible for children and youth services, and Sylvia Jones, the health minister, declined interview requests.
Multiple child advocates support the family’s call for an inquest, saying a hearing is needed to examine the systemic issues that contributed to Jade’s death.
Kiaras Gharabaghi, a professor of child and youth care and dean of the faculty of community services at ɫɫ Metropolitan University, said Jade’s story underscores the need for an overhaul of the systems meant to protect vulnerable children.
“There’s been a real lack of courage on the part of governments to take a hard look as to whether or not the institutions we built decades ago are still relevant for the 21st century,” Gharabaghi said. “The world has changed, and our institutions haven’t.”
Coroner’s inquests do not assign blame, but produce recommendations to prevent similar deaths.
It’s the chief coroner’s job to speak for the dead to protect the living, said Irwin Elman, who was Ontario’s child and youth advocate from 2008 to 2019. Elman said the coroner has the authority to call a discretionary inquest and must do so.
“Someone has to stand up, take responsibility and make change,” he said. Jade’s story is representative of “hundreds, if not thousands, of children in the province.”
Elman also stressed the need to transform Ontario’s reactive child welfare system into one that supports children and families long before they reach a crisis point, pointing to efforts underway in B.C. as a model.
The unsettling disclosure comes 20 years after the ombudsman first flagged forced abandonment as a concern — but systemic issues persist.
The unsettling disclosure comes 20 years after the ombudsman first flagged forced abandonment as a concern — but systemic issues persist.
Separate from a coroner’s inquest, a provincial committee called the unit investigates the deaths of children who died while in CAS care and makes recommendations to prevent future harm.
The CYDRA unit is supposed to decide if the children’s aid society must launch an internal child death review within 21 days of a death; the process is outlined in a joint directive between the coroner’s office and the ministry of children, community and social services. That review must be led by an independent expert and completed within roughly five months, and it’s used to inform CYDRA’s work.
Nearly nine months after Jade’s death, London CAS has not been told whether or not to launch a formal review.
Last month, a spokesperson for the coroner’s office told the Star that, in practice, the 21-day timeline “is not firm.” The ministry website adds that “there are a number of circumstances that impact and often delay” the ability to meet the target, including that autopsies and coroner’s reports can take many months to complete.
As of mid-June, the CYDRA review hadn’t started. Jade’s parents have asked for an update but haven’t yet received one. The coroner’s office spokesperson said they cannot comment on the status of individual child death investigations but said “the death of a child or youth is a tragic event” and “each death investigation is unique.”
The London CAS said it has an internal policy to review the circumstances of any child death separately from the CYDRA requirement.
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