Chief Coroner Review 2025-14478

Ministry of the Solicitor General

Office of the Chief Coroner
Ontario Forensic Pathology Service

Forensic Services and
Coroners Complex
25 Morton Shulman Avenue
Toronto ON M3M 0B1

Telephone: (416) 314-4000
Facsimile: (416) 314-4030

C25-147

Chief Coroner Review
2025-14478
June 25, 2025

Purpose
The Office of the Chief Coroner for Ontario serves the living through high quality death investigations and inquests to ensure that no death will be overlooked, concealed, or ignored. The findings of death investigations inform potential improvements in the health and safety of the public and in the prevention of deaths.

A Chief Coroner Review was undertaken to learn from the circumstances of the tragic death of a 26 month-old child in a septic system to inform potential recommendations to prevent further deaths. A meeting of members from relevant organizations was convened by the Chief Coroner to discuss the events leading to the death, provide opportunity for discussion about specific insights the participants may have about public safety issues relating to the death, and bring forward and discuss potential recommendations.

Participant Organizations
Association of Municipalities of Ontario, College of Early Childhood Educators, Concrete Precasters Association of Ontario, Ministry of Education, Ministry of the Environment, Conservation and Parks, Ministry of Municipal Affairs and Housing, Northumberland County, Office of the Chief Coroner, Office of the Chief Medical Officer of Health, Ontario Association of Sewage Industry Services, Ontario Onsite Wastewater Association, Ontario Provincial Police, Reliable Reporting.

Circumstances of the Death
On May 25, 2023, at 5:17 p.m., 911 calls were made from a daycare reporting a child to be missing. Emergency responders attended the address and searched the property. First responders were notified of an opening into the septic tank within the fenced toddler play area and subsequently the child was found without vital signs in the septic holding tank.

The daycare was licenced by the Ministry of Education in November 2011 and employed ten employees at the time of the death. The daycare had a total capacity of 27 children and was following the Ministry required ratios on the day of the death.

Inspections of the daycare were completed by the Ministry of Education on February 1, 2023, and the Public Health Unit on February 23, 2023. Neither of these inspections reported any concerns regarding the septic system, although neither inspector reported awareness of the septic tank access point within the toddler play area. There were no reported problems with the septic system leading up to May 25, 2023.

The septic system was installed in 2011 with post installation inspection by an inspector from the local health unit. The septic system had three lids, one of which was located inside the toddler play area. The septic lid and riser require four screws to be inserted vertically to secure the lid to the riser, and two safety screws to be inserted horizontally to further secure the lid to the riser. The septic system was regularly serviced by the same septic company and last pumped on November 30, 2022. The septic lid was reported to have been secured after the last pumping. No information was reported regarding any problems with the septic system or any servicing after November 30, 2022.

Investigation determined that the septic lid inside the toddler play area was insecure and had screws missing at least six weeks prior to the death. The investigation indicated that safety screws on the septic lid had not been installed in the time since the septic installation in 2011. None of the three septic system access points had a secondary safety device installed under the lids within the riser that could prevent someone from falling into the access points in the event the lid broke or become insecure. Note: It is now required that all new septic tank installations must include installation of a secondary safety device in all access points.

Playground safety inspection checklists were completed by daycare staff each morning and afternoon, prior to children accessing play spaces. The septic system lids were not included on these checklists. The investigation revealed that not all staff were aware of the septic access points within the toddler play area, nor the hazard posed in the event the lid was not secure.

At the time the child went missing, there were five children remaining in care with three staff present. The child was last observed in the toddler play area at 4:48 p.m. At 4:54 p.m., the whereabouts of the child was unknown to the staff. Staff who had left for the day returned to assist with searching for the child.

During a search, the septic tank lid was observed to be partially covering the hole and upside down. At 5:15 p.m., the child’s mother arrived for pickup and was informed her child was missing. Police arrived by 5:20 p.m. and, upon discovering the unsecured septic tank lid, requested fire services attend with subsequent recovery of the child from the septic tank. Full resuscitation efforts were unsuccessful.

Recommendations

To the Ministry of Education:
1. Revise the Child Care Licencing process to include a requirement that at the time of review of a new application or renewal of a Child Care Licence:

• Septic tank access points cannot be present within a children’s outdoor play area.
   
• When a septic tank will be located on the premises of the licensed child care setting, but not present within a children’s outdoor play area, the following requirements must be considered:

               o All septic tank access points are secured according to manufacturer directions.

               o All septic tank access points have a properly installed secondary safety device (e.g., lock safety screen, safety lid, safety net, safety star).

                         - Note: there may be benefit from involving qualified septic tank inspectors to assess the safety of the septic tank access points.

               o All septic tank access points are inaccessible to children, e.g., fence, concrete lid, cast iron framing gate.

• Concurrent with renewing a Child Care Licence, there is a well-defined approach to confirm compliance with these requirements within a specified time period.

NOTES:

• This information should be available to potential Child Care Licence applicants and renewing licence holders.
   
• Consideration should be made for implementation of this recommendation for all schools and other educational settings.

2. Consider enhancements to ministry Child Care Licencing requirements to include the following:

• A comprehensive tour of the licenced child care setting should be offered to parents/caregivers at the time of application for a child to attend the licenced child care setting.

               o The tour should include:

                         - All areas that are accessible by children, and

                         - Potential safety hazards should be highlighted with discussion of measures in place to mitigate risk.

• Licenced child care operators to create and maintain emergency response policies and procedures including:

               o Clear outline of the importance of an immediate response at the time of an urgent circumstance

               o Specific direction about when to call 911

               o A specific approach for response to a missing child

               o Determination of an acting supervisor in the absence of the defined supervisor, and

               o Process for staff awareness and training including regular emergency response practice drills.

• Licenced child care operators to create safety hazard polices and procedures including:

               o Ensuring awareness of all safety hazards present in the licenced child care setting (including septic tank access points).

               o Measures to mitigate risk of injury associated with all safety hazards present, and

               o Approach to staff training, including at the time of new employment and frequency of refresher/updated training.

3. To ensure ongoing recognition of and monitoring for the danger of septic tank access at a licenced child care setting:

• Risk of septic tank access should be included in the ministry Child Care Licencing requirements as one of the defined safety hazards inspected each time a safety checklist is completed.
   
• Ministry inspection processes should include training for all ministry inspectors on specific potential safety hazards, including septic tanks. Each site visit should include specific checks of all potential safety hazards, including potential septic tank access points.

4. Share the Report of the Chief Coroner Review and recommendations with all licensed child care operators with a requirement to share it with all employees to raise awareness about and promote septic tank safety.

To the Ministry of Education and the College of Early Childhood Educators
5. Consider reviewing and revising the minimum staffing requirements for licenced child care settings including:

• The ratio for the minimum number of employees to children for operation of a licenced child care settings across all age categories.
   
• Increase in the number of qualified employees (i.e., a registrant of the College of Early Childhood Educators or an employee who has otherwise been approved by the Ministry of Education) and/or eliminating the periods of reduced ratio for pick-up and drop-off times.

6. Consider amending Regulation 221/08: Registration under the Early Childhood Educators Act to provide for an Advanced Practice Class of membership with the College of Early Childhood Educators to support enhanced expectations of supervisors working in licenced child care settings.

To the Chief Medical Officer of Health
7. Working with provincial public health units, consider reviewing and revising the approach to:

• Regular inspections of licenced child care settings to include all potential health and safety hazards, including septic tank access points.
   
• Public Health inspections of septic tank systems to include:

               o A standard inspection checklist addressing potential safety issues, specifically risks associated with septic access points (and the importance of                       a secondary safety device).

               o Requirements for inspection at licenced child care settings as well as other high-risk settings, e.g., public settings frequented by children, and

               o Requirements for training to support informed and effective inspections.

To the Chief Medical Officer of Health and the Ministry of Municipal Affairs and Housing:
8. Support municipalities and public health units in developing a process to receive concerns/complaints regarding septic tank safety, including training and a robust tracking and enforcement process that considers inspection, compliance, penalties, and resolution.

To Ontario Association of Sewage Industry Services, Ontario On-site Wastewater Association, and Concrete Precasters Association of Ontario:
9. Work together to collaboratively develop and widely distribute best practice safety expectations for septic tank installation and pumping including:

     a. A standard inspection checklist, including location specific considerations, e.g., licenced child care settings

     b. Secure closure of septic tank access points

     c. Importance of secondary safety devices being present and properly installed

     d. Inspection of septic tank lid screws and screw holes to ensure that they can be adequately secured and are not damaged

     e. Any existing safety concerns to be communicated in writing to the property owner, before leaving the site, for resolution, and

     f. Significant septic tank safety concerns should be reported to the Chief Building Officer at the relevant municipality, and/or the local public health unit             in locations without a Chief Building Officer.

To the Association of Municipalities of Ontario, the Rural Ontario Municipal Association, the Ontario Association of Sewage Industry Services, Ontario On-site Wastewater Association, and Concrete Precasters Association of Ontario:
10. Work collaboratively to create and implement a public awareness campaign that leverages existing public education resources and pamphlets about septic tank maintenance and safety that can be widely distributed to municipalities, homeowners, not-for-profit organizations, and businesses.

• With family consent, the campaign could include sharing of the tragic circumstances provided in the Report of the Chief Coroner Review to raise awareness about and promote septic tank safety.
   
• Explore funding opportunities to support the campaign in achieving public safety awareness.

11. Consider leveraging the existing Septic Awareness Week to promote regular safety checks of septic tank access points and secondary safety catches, e.g., like public reminders about checking smoke and carbon monoxide alarms.

To the Ministry of Environment, Conservation and Parks and Ontario Association of Sewage Industry Services:
12. Work together to consider the establishment of a new licensing regime for septic pumpers and haulers in Ontario to support the establishment of professional standards to promote public safety.

• Professional standards could support:

               o Approach to education and training,

               o Adherence to safety standards,

               o Performance expectations,

               o Accountability, and

               o Complaint mechanisms.