On a late afternoon in April, Justin Sangiuliano put on his helmet and gloves to go for a bicycle ride.
But staff at the unlicensed Oshawa group home where the 17-year-old developmentally disabled teen lived were planning to take him fishing instead. They locked the bicycle shed to be sure the energetic 6-footer got the message.
Justin was furious. He stormed around the home, swinging his fists until staff grabbed his arms to restrain him. Kicking and screaming — and still in the clutches of two staff members — the teen fell to the living room floor, where he reportedly rubbed his face back and forth on the carpet until his forehead, chin and cheeks were raw.
Some time later, he stopped struggling and staff released him. But Justin never got up. He was rushed to Lakeridge hospital and arrived without a heartbeat, according to a serious occurrence report filed by Enterphase Child and Family Services, the private company that runs the group home.
The group home where 17-year-old Justin Sangiuliano lived (Rick Madonik/Torstar News Service)
Justin, a ward of the children's aid society in Timmins, Ont., never regained consciousness and died five days later.
Under Ontario's current child protection system, his story might never have been told, because authorities concluded that neither criminal charges nor an inquest were warranted.
"It is stunning to me how these children... are rendered invisible while they are alive and invisible in their death," said Irwin Elman, Ontario's independent advocate for children and youth. Elman was unaware of Justin's death until informed by the Star. Between 90 and 120 children and youth connected to children's aid die every year.
Durham Regional Police investigated the April 16 incident and laid no charges. Dr. Jennifer Arvanitis, the regional supervising coroner, said her "investigation is complete and there are no plans to call an inquest."
Although the results of coroner's investigations in Ontario are private unless there is an inquest or a trial, a source close to the case has said an autopsy showed Justin had an undiagnosed heart condition.
Enterphase's executive director, Harold Cleary, declined to discuss the case due to the company's privacy policies.
However in an emailed statement, Cleary noted that a Durham Children's Aid Society investigation of the incident concluded "there are no current child protection concerns that require ongoing involvement... staff administered (the physical restraint) appropriately."
Zabrina Sangiuliano and her brother Justin, who died on April 21, 2015, at age 17 (FAMILY PHOTO)
Physical restraint, which can include immobilizing a child or youth by holding the child by the shoulders and wrists with their arms extended, as happened with Justin, is controversial in group homes. The practice resulted in two high-profile inquests into the deaths of two children restrained in Brampton and Peterborough-area homes in the late 1990s.
A Star analysis of serious occurrence reports filed to the Ministry of Children and Youth Services by Enterphase shows the agency's use of restraints in 2013 and 2014 is about twice the provincial average of 36 per cent for that time period.
According to documents obtained through freedom of information requests, restraints were used in 451 of the 633 serious occurrence reports filed by Enterphase during this time — a rate of 71 per cent.
From January to mid-May 2015, there were 84 cases of restraints out of 152 serious occurrence reports, for a rate of 54 per cent.
Cleary, whose agency has a capacity to serve 47 children and youth in nine licensed homes in the GTA and Peterborough area, said he does not think his restraint rates are excessive.
"However, Enterphase is always looking for ways to further reduce the use of restraint," he said in his email to the Star. "The goal of reducing restraint is part of our agency culture."
Zabrina Sangiuliano kids around with brother Justin (FAMILY PHOTO)
Children's ministry officials met with Enterphase in 2013 "to discuss expectations around serious occurrence reporting requirements relating to physical restraints in their licensed sites," a spokeswoman told the Star in an email.
"Following the incident of April 2015, the ministry has undertaken a full licensing review for this location, given the type of service provided there," said Aly Vitunski, spokeswoman for Children's Minister Tracy MacCharles, referring to Justin's death at Enterphase's home on Centre St. S. in Oshawa.
Cleary noted that under current ministry regulations, group homes like the one Justin was in — with fewer than three children or youth — do not require licences. Enterphase is also an accredited children's mental health centre, he added.
Regardless of credentials or number of children served, Elman said he wants the ministry to ensure all group homes are licensed.
As a provincially appointed panel reviewing residential services for children and youth prepares to report at the end of the year, Elman and other advocates say Justin's death raises serious questions about the use of restraints on vulnerable children and youth in the care of children's aid. The secrecy surrounding the incident, they add, is even more alarming.
"I think there should be an inquest in this case — in all cases when children die in the care of the government," said Elman, who has called for the province to reduce the use of physical restraints to zero. "We need to have a public, open discussion about how we cared (for) and protected that child.
On Monday, the Legislature passed a private member's bill introduced by NDP children's critic Monique Taylor that will require children's aid societies and other agencies to inform the advocate's office when a child or youth in care has died or suffered serious injury. The law will come into effect next year.
Elman, who has been seeking this information since he was first appointed in 2008, argues it will help him in his duty to investigate and report concerns to the Legislature.
"It's no longer OK for the coroner to go behind closed doors with the ministry and perhaps a representative of the child welfare agency involved and say: 'Nothing to see here. Move along,' " he said.
Justin's death comes amid an ongoing Star investigation that has revealed an unaccountable and secretive child protection system and the recent auditor general's report, which outlined a litany of problems including improperly conducted investigations into child abuse and the government's failure to fully enforce standards.
A Star analysis of serious occurrence reports in Toronto group homes in 2013 found one in three involved the use of physical restraints.
From 2010 to 2015, data recently obtained by the Star shows there were about 45,000 physical restraints in Ontario, according to reports filed to the Ministry of Children and Youth Services. That is about 36 per cent of the 126,400 serious occurrences reported to the ministry by agencies serving vulnerable children and youth, most of them referred by children's aid societies.
Under provincial regulations, physical restraints can be used only to prevent a group home resident from injuring themselves or others, or from causing significant property damage.
They can be used only when less intrusive methods have been tried or deemed not to be effective.
As a result of deaths in the late 1990s, provincial regulations were changed to require ministry-approved training in physical restraints for all front-line staff.
However, the children's ministry does not know how many children or youth have died after being physically restrained in group homes since those measures were introduced.
Coroner's reports are generally confidential and released only to family members upon request. Since most Crown wards don't have family who would notify the media or seek help from the provincial advocate, it is difficult for the public and those working in the field to know what is happening, Elman said.
Although the government lists six approved training programs in the use of physical restraints, no one has looked at which techniques are best, said Kim Snow, an associate professor at Ryerson University's School of Child and Youth Care.
Justin Sangiuliano, who loved animals, with the family dog in Matheson Ont. (FAMILY PHOTO)
"Is one safer than the other? Should one be used in certain situations and not others? Should we only use this type of restraint on little kids versus another type of restraint on big kids? Sometimes staff can't contain kids using a restraint. So what happens when those situations occur," she said.
"Until we can answer those questions, the risk of harm as a result of restraints is quite high. For staff and kids."
Snow, who has worked in the field for more than three decades, including several years in the 1980s running group homes, also wants the province to track the use of restraints more closely.
"We can't continue to have these things hidden and continue to practice these interventions and not expect further injury," she said. "These are our most vulnerable children... If we don't have mechanisms to review this, the cycle is going to continue. If anything, it's going to get worse."