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Investigative Reviews

Section 9(2)(d) of the Child and Youth Advocate Act provides the Advocate with the authority to conduct investigative reviews:

The Advocate may investigate systemic issues arising from a serious injury to or the death of a child who was receiving a designated service* at the time of the injury or death if, in the opinion of the Advocate, the investigation is warranted or in the public interest.

* The Child and Youth Advocate Act defines a designated service as:

  • A service under the Child, Youth and Family Enhancement Act, other than an adoption service under Part 2 of that Act
  • A service under the Protection of Sexually Exploited Children Act
  • A service provided to children in the youth justice system (in open or secure custody at the time of the incident)

Investigations Process Chart

Click here to view a description of OCYA’s investigations process.


The Advocate receives an initial alert providing notification that a child receiving services from the Ministry of Children’s Services has died or has been seriously injured. Following the “Alert,” a Report of Serious Injury or Death is received which provides a one to two page summary of the incident, information on the family, and a brief overview of ministerial involvement. The Report of Serious Injury or Death is typically received within two weeks of the initial notification.


Information provided in the Report of Serious Injury or Death is reviewed, along with the child’s electronic file history. OCYA investigators also make contact with involved parties such as the Office of the Chief Medical Examiner, Alberta Health Services or police. The purpose of the Examination is to determine whether more information is required to determine any potential systemic issues. The review may be concluded at this phase or it may move to Assessment.


If there are issues that might affect other young people, the review proceeds to Assessment. During this phase, the investigator completes a detailed review of all paper documentation and contacts others to identify potential systemic issues. The review may be concluded at this phase, or it may move to full investigative review if the Advocate determines it is warranted.

Full Investigative Reviews

If the Advocate determines that a full Investigative Review is warranted, a Terms of Reference is drafted to guide the Review and is shared with the Council for Quality Assurance for their input. Full Investigative Reviews involve interviews (which may include family members), the review of additional documentation and research, and analysis of the young person’s circumstances.

A draft report is developed and shared with a committee of subject matter experts who provide input into the findings and recommendations. The involved Ministry is provided the opportunity to identify any facts that they believe to be incorrect in the young person’s history. An independent privacy expert reviews the report to ensure that the young person’s privacy is maintained (all reports are non-identifying). And, independent legal counsel reviews the report to ensure that the Advocate is within his authority to conduct the Review.

The Advocate releases a public report when the Investigative Review is complete. Prior to releasing the report, the Advocate meets with the involved Ministry to inform them of the findings and recommendations.

An Investigative Review does not assign legal responsibilities, nor does it take the place of other processes that may occur, such as investigations or prosecutions under the Criminal Code of Canada. The intent of an Investigative Review is not to find fault with specific individuals, but to identify key issues along with meaningful recommendations which:

  • are prepared in such a way that they address systemic issue(s);
  • and specific enough that progress made on recommendations can be evaluated;
  • yet, not so prescriptive to direct the practice of Alberta government ministries.

It is expected that ministries will take careful consideration of the recommendations, and plan and manage their implementation along with existing service responsibilities. The Advocate provides an external review and advocates for system improvements that will help enhance the overall safety and well-being of children who are receiving designated services. Fundamentally, an Investigative Review is about learning lessons, rather than assigning blame.

Reports Released to Date

Click here for a full listing of OCYA Investigative Review reports released to date.