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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.

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)

Systemic reviews are generally completed within 18 months of the young person passing away and include findings, observations and/or recommendations to improve supports and services for young people.

Mandatory Reviews

On March 30, 2018, the mandate of the Advocate to conduct investigative reviews expanded when the Child Protection and Accountability Act (also known as Bill 18) was proclaimed and embedded into the Child and Youth Advocate Act under Section 9.1 Mandatory review of death. The Act gave the Advocate the authority to conduct mandatory reviews when a young person passes away while receiving child intervention services, as a child in need of intervention, at the time of death or within two years of their death.

The Act requires the Advocate to publically release mandatory reviews within one year of notification of a young person’s passing and comment on findings, observations and/or make recommendations. The Advocate has decided that mandatory reviews will be released twice a year (March and September).

Investigations Process Chart

Click here to view a description of our investigations process.


We receive notifications of death, or serious injury, of a young person from four sources: Children’s Services, the Office of the Chief Medical Examiner, Justice and Solicitor General and Vital Statistics.

Opening Phrase

We request and review information from ministries and organizations involved with the young person, gathers collateral information and prepare a preliminary investigation report. The purpose of the preliminary investigation report is to make a recommendation regarding whether to move the matter to the next phase or to conclude our involvement.

Mandatory reviews will always move to the next phase while systemic reviews may conclude at this phase if it is determined that there are no potential systemic issues present.

Investigation Phase

If a determination is made that the matter will proceed to an investigation, our investigators complete draft terms of reference and an investigation plan. During this phase, the investigators conduct a detailed review of all documentation, inform and involve relevant stakeholders (as per section 9(8)(9) and 9.1(9)(10)), conduct interviews with family and those who provided services to the young person, and prepare the draft #1 report. This report contains a chronology of the young person’s circumstance along with areas identified for further exploration.

Once the Advocate approves the draft #1 report, the investigators finalize the terms of reference, gather further information, identify relevant research and consult with subject matter experts who provide input into findings, observations and/or recommendations.

The investigators put this information into a draft #2 report which includes a chronology of the young person’s circumstance along with findings, observations and/or recommendations related to public assurance, services and support and/or systemic issues. The young person’s chronology is sent to the involved ministries for them to identify facts that they believe to be incorrect. An independent privacy expert reviews the report to ensure that the young person’s privacy is maintained (all reports are non-identifying). Independent legal counsel also reviews the report to ensure the Advocate is within his authority to conduct the Review.

Once this process is complete, the investigators create a final investigative review report that includes a chronology of the young person’s circumstances along with research, findings, observations and/or recommendations.

Closing Phrase

The Advocate meets with the involved ministries to inform them of the findings, observations and/or recommendations in the investigative review report. The investigators inform the relevant stakeholder (as per section 9(8)(9) and 9.1(9)(10)) that our involvement is concluded and the outcome. The Advocate releases a public report when the investigative review is complete.

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.