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Investigative Reviews

The Child and Youth Advocate Act (CYAA) provides the Child and Youth Advocate (the “Advocate”) with the authority to conduct systemic and mandatory investigative reviews when a young person is seriously injured or dies who has involvement with the child intervention system or the youth justice system.

Systemic Reviews

Section 9(2)(d) of the CYAA mandates a systemic review when a young person is seriously injured or passes away while receiving designated services at the time of the serious injury or death, or had received child intervention services within two years of their 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)

It is expected that systemic reviews will be completed within 18 months of the young person’s death or serious injury. Reviews will include findings, observations and/or recommendations to improve supports and services for young people.

Mandatory Reviews

On March 30, 2018, the Child Protection and Accountability Act (also known as Bill 18) was proclaimed and became embedded into the Child and Youth Advocate Act (Section 9.1 Mandatory Review of Death). Now, the Advocate must conduct a mandatory review when a young person dies while receiving child intervention services, who has been identified as a child in need of intervention, at the time of their death or within two years of their death.

The Advocate must publicly release mandatory reviews within one year of notification of a young person’s death. Public reports must contain findings, observations and/or recommendations. Mandatory reviews are released twice a year (March and September).

Investigations Process

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


Children’s Services, the Office of the Chief Medical Examiner (OCME), Vital Statistics and or Justice and the Solicitor General notify the Advocate when a young person has passed away.

The Ministries of Children’s Serviices and Justice and Solicitor General notify the Advocate when a young person is seriously injured. A serious injury is defined as near fatal and/or resulting in life-long impairments to a young person’s health.

Preliminary Investigation

Initially, we conduct a preliminary investigation by reviewing information from a number of sources (ministries and organizations involved with the young person such as Children’s Services, Health, Education, etc.) and speak to at least one individual who was close to the young person. The purpose of the preliminary investigation is to determine whether a full investigation is warranted.

Mandatory reviews must move to a full investigation while systemic reviews may conclude, if it is determined that there are no potential systemic issues.


If the matter proceeds to investigation, Terms of Reference and an Investigation Plan are developed. The investigators review the Preliminary Investigation report, gather and review additional information, inform and involve relevant stakeholders (as per section 9(8)(9) and 9.1(9)(10)), and conduct interviews. It is important that family members and are involved in this process. Subject matter experts are consulted. A draft report is prepared that contains a summary of the young person’s history and circumstances along with an initial analysis.

The young person’s history is sent to the involved ministries for fact checking. An independent privacy expert reviews the report to ensure that the young person’s privacy is maintained (all reports are non-identifying). An independent legal review also occurs to ensure that the Advocate is within his authority to conduct the Review.

Once this process is complete, the report is finalized. It contains findings, observations and/or recommendations related to public assurance, services and supports, and/or systemic issues.

Final Report

After the report has been finalized, meetings occur with family members and organizations that had involvement with the young person. The purpose of these meetings is to walk through the findings, observations and/or recommendations before the report is publicly released. Relevant stakeholders (as per section 9(8)(9) and 9.1(9)(10)) are informed that our involvement is concluded and provided with an overview of the outcome.

The Advocate releases the public report which is posted on our website.

The Investigative Review does not assign legal responsibilities, nor does it replace other processes that may occur, such as investigations or prosecutions under the Criminal Code of Canada. The intent of the Investigative Review is not to find fault with specific individuals, but to recognize good practice and/or identify key issues along with meaningful findings, observations and/or recommendations, which are:

  • 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 involved with designated services. Fundamentally, the 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.