A teen from Grassy Narrows wasn't the only one to die, while in care. Doctor Dirk Huyer is Ontario's Chief Coroner, and he counts 12 youth who've died in care over the last four years.
"These are terrible tragedies. Young people who died way, way too young," he said.
Azraya Kokopenace, 14, died in the spring of 2016 near Kenora's hospital. Initially, the panel looked at five deaths, but soon found similarities among a dozen cases.
"It certainly showed, what the panel thought, is there is no system," the coroner continued.
"Kids were placed into locations where it was believed they were going to get helped, be protected, be safe and come out as healthier and happier. Unfortunately, it failed the kids," Huyer concluded.
Panel members included Treaty 3 Elder Sherry Copenace, who teaches social work at the University of Manitoba. Theresa Stevens, who was the executive director for Anishinaabe Abinoojii Family Services, also made a presentation to the panel. Stevens now leads the Association of Native Child and Family Service Agencies of Ontario.
The report echoes the findings of a report last year by the province, along with calls for better funding for First Nations agencies and the reunification of children with their families on First Nations.
Last year, along with new legislative reforms, the province budgeted an additional $134 million over four years, in an effort to better assist 113,000 families in need.
Kenora's hospital has requested $1.5 million for a 24/7 children's crisis service to help with at-risk youth. In 2016-2017, hospital staff estimated they received more than 360 youth in crisis, and they said the numbers were on the rise.
The report didn't include the death of Hezekiah Wesley in the spring.
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