Manitoba Advocate for Children and Youth Releases First Public Child Death Report Under New Mandate

October 19, 2018 – MANITOBA –In her first publicly released child death investigation since the proclamation of The Advocate for Children and Youth Act in March 2018, Manitoba Advocate for Children and Youth, Daphne Penrose, shares the story of an Indigenous youth who died tragically in a vehicle accident in a rural community.

“This is the story of a young man who was loved dearly by his family,” said Penrose as she summarized the report, “and many of the public child-serving systems in Manitoba were involved with him and his family in the final five years of his life.” The report, Documenting the Decline: The Dangerous Space Between Good Intentions and Meaningful Interventions investigated and analyzed services that were provided to the youth by education, mental health, addictions, youth justice, and child and family services. The Advocate’s investigation reveals that while there were good intentions from service providers, those services did not provide the meaningful interventions he needed and missed countless opportunities to help him change the course of his life.

“We have not named this youth,” explained Penrose, “because while my legislation allows my office to gain access to and comprehensively review provincially-funded system providing services to children and youth, the federal Youth Criminal Justice Act expressly prohibits me from publicly identifying any young person who had involvement with that federal system.”

Throughout the course of her investigation, the Advocate’s office consulted with the family of the youth, which is a long-standing practice at the office. “We know that service files do not paint a full picture of a child, and so we always invite the participation of family and others who knew and loved the child,” Penrose noted, “By travelling to the home communities, sitting with families, and listening to their stories of the child they loved, our ability to assess accurately the quality of services is made all the richer.” In this story, since the Advocate is prevented from publicly naming the youth, the Advocate asked the family to provide the name for the report, and the family asked the Advocate to use his Spirit Name, Circling Star. In the time leading up to today’s release, the Advocate and members of her team met again with Circling Star’s mother to review the final draft. “We are honoured and grateful that Circling Star’s family has endorsed this report and its recommendations,” Penrose shared, “They hold hope that in his memory, improvements to systems can be made so as a province we can prevent future tragedies from occurring in similar circumstances.”

Documenting the Decline is a collection of missed opportunities. It includes descriptions of the many public services that never worked together in any meaningful way to support a boy who was in a deepening crisis. After two particularly significant events in Circling Star’s life, many public services became involved. However, instead of coordinating their interventions in the small region in which Circling Star lived and attended school, these public systems worked in isolation from each other and, as such, delivered disjointed services to Circling Star and his family. They were ill-coordinated and sometimes even worked at cross purposes.

In today’s report, the Advocate makes six formal recommendations for changes to public systems. Among others, these include calling on the government to implement one of the key recommendations from the recently-released “Virgo report,” so existing barriers are eliminated and so young people can access mental health supports, especially for Indigenous youth, who continue to experience persistent challenges to service access at times when they most need the support. Further, building on her recently released statement of concern regarding addiction treatment for Manitoba youth, the Advocate makes the recommendation today that the province must move immediately to work with frontline services and subject matter experts to create a youth addiction action strategy. Additional recommendations are made to Education, Justice, and CFS.

“There is no more important work that we must do,” Penrose urged, “When a child has died, we have an obligation to learn lessons and make changes so we can find the gaps in our systems and move quickly to ensure we are doing everything we can to fix those gaps and prevent the deaths of other children.”

“We have to see each child as all of our responsibility,” Penrose concluded, “The expertise and the passion exist here in our province and so, if we work together, we can improve the lives of all children and youth.”

While today’s report is the first child death report publicly released, the Advocate is also looking ahead and she noted that her team is concluding special reports on several additional matters, which she intends to release publicly in the coming months. Documenting the Decline: The Dangerous Space Between Good Intentions and Meaningful Interventions is available from the website of the Advocate:


The Manitoba Advocate for Children and Youth Office is an independent office of the Manitoba Legislative Assembly, which represents the rights, interests and viewpoints of children, youth, and young adults throughout Manitoba. We do this by advocating directly with children and youth and by reviewing public services after the death of any young person who received child welfare services in the year preceding their death. The Manitoba Advocate is empowered by legislation to review, investigate, and provide recommendations on any matter relating to the welfare and interests of children, youth, and young adults throughout Manitoba.

For media enquiries contact:

Ainsley Krone, Deputy Manitoba Advocate,, or at (204) 451-3190.


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