Recommendations to Improve Child Safety from Ontario’s Chief Coroner

Ministry of Education
Early Years and Child Care Division

315 Front Street West
Toronto ON M7A 0B8

Date:                                     December 16, 2025

Memorandum To:      Child Care Licensees

From:                                   Holly Moran
                                                  Assistant Deputy Minister
                                                  Early Years and Child Care Division

Subject:                             Recommendations to Improve Child Safety from Ontario’s Chief Coroner

Good day,

I am writing today to share the final report from a Chief Coroner Case Review that was conducted this past year. The findings of death investigations inform potential improvements in the health and safety of the public.

Last June, a Chief Coroner Case Review was undertaken to learn from the circumstances surrounding the death of a two year old child who fell into a septic system at a licensed child care centre in May 2023. This case review resulted in recommendations to improve public safety directed at several different organizations, including the Ministry of Education.

The ministry supports these recommendations and will be acting on many of them in the coming months. It is likely that regulatory changes to O. Reg 137/15 under the Child Care and Early Years Act, 2014 (CCEYA) will be required. The ministry plans to consult on any proposed regulatory changes in 2026 and will provide additional information as it becomes available.

Additionally, as recommended by the Chief Coroner, we have attached a copy of the report for you to review and share with others in your organization. Please be advised that the report includes detailed information about the circumstances of a child’s death, which may be distressing and challenging to read. I encourage you to review and reflect on the findings with care, and to engage your staff, providers and volunteers in discussions about the recommendations and how to improve safety in your program.

While many of the recommendations address specific risks associated with septic systems, there are recommendations that are relevant for all programs. This is an opportunity to reinforce the importance of safe play spaces with your staff, providers and volunteers and to identify and address any potential hazards in your program environments. Please consider examining your site carefully, identifying any possible hazards in play spaces, including septic access points, and proactively put measures in place to reduce the risk of harm or death.

If your child care centre currently has a septic system on site, please complete this short survey before January 17, 2026. The survey should only take a few moments to fill out and will help us understand more about the use of septic systems in licensed child care centres.

Septic Access Point Survey: – Fill out form

Property owners are responsible for the maintenance and upkeep of their septic system and septic tank access points should always be secured properly to prevent injury and death. Recent updates to Ontario’s Building Code require that newly installed septic systems meet an updated safety standard that includes a requirement for a secondary safety screen beneath tank covers to enhance public health and safety; however, older septic systems may not have this feature in place. For child care sites with septic systems, I strongly encourage you to review the safety features of your system, working with your landlord if necessary, and install a secondary safety screen if you do not already have one in place.

If you are concerned about an unsafe septic system, please contact your local municipal building department or Chief Building Official to submit a complaint. You may also wish to review the information on Septic systems | ontario.ca and download a copy of the SepticSmart! resource which provides general information on how septic systems work.

The health and safety of children is a shared priority across our sector. By learning from this case review, we can take meaningful action to strengthen safeguards and prevent future harm.

Please email childcare_ontario@ontario.ca if you have any questions or concerns. Thank you for your continued commitment to Ontario's children and families.

Sincerely,

Holly Moran

c. Consolidated Municipal Service Managers and District Social Services Administration Boards (CMSMs and DSSABs)

Early Years and Child Care Division Directors

Attachment:

C25-147 Chief Coroner Case Review Report