"Picture big brown eyes that danced with laughter when he was having fun and enjoying life. Yet, these same eyes sometimes hid the sadness of trying to make sense of his new home in Canada and the challenges of finding a place each day in school and the community.
"He wanted those around him to be proud of him, he did not want to be seen as a burden. Like all youth he wanted to fit in, to be included, to be loved and to be safe."
This is how the Office of the Chief Coroner described a young boy in a new report following a review of his death by suicide nearly two years ago. Though the report doesn't identify the boy by name, Durba Mukherjee says it details the story, widely covered in the media, of her 12-year-old son Arka Chakraborty. The report comes following the months-long quest of Mukherjee and advocates to uncover the "systemic failures" that they say could have contributed to his death amid bullying by his peers.
While Mukherjee says the report provides her with some solace, the work is not done. The report outlined 23 recommendations for various bodies including government ministries, school boards, child welfare organizations and the coroner's office itself.
The chief coroner's office said the purpose of the Local Death Review Table process, which led to this report, is to "identify gaps and/or issues that may have contributed to the circumstances of the death and identify opportunities for recommendations to be made that may inform death prevention efforts, at the local and/or systemic levels." It also allows community participants to "influence change" in organizations or the government.
Chakraborty's death followed what the report described as reported isolation and bullying "as a result of the shame and stigma that can result from divorce and a break in family honour." Mukherjee had recently moved to Canada from India with her son after what the report detailed as many years of "violence, discrimination and seemingly subsequent trauma."
"The coroner's report actually gave me a lot of peace," Mukherjee told QP Briefing. "(It was the) first time in these two years I really felt relieved that OK, at least now ... some of this system, they acknowledged the fact that my boy was not a criminal who deserved to die so soon."
The report finds Chakraborty was a victim of ongoing bullying and explores an incident his family believes contributed to his death. It says Chakraborty "came into the possession of a hand-held gaming device that belonged to another student" shortly before his death. The report added there were conflicting reports of how this happened, with some accusing the boy of stealing it, but that he returned it to the owner the next day. The coroner's report said "the handling of this incident by the adults involved did not seem to consider this young person’s safety at the forefront of the interventions."
Mukherjee said she thinks the report is "unbiased" and she felt heard through the process, but that documentation alone won't help.
"What if another child falls in the same situation? So unless the recommendations that they have made ... are implemented, and I see that the other children, other people of my community, they are seeing the benefits of this, I don't think we can say, 'Okay our job is done,'" she said. "My son is gone, I can never get him back, but ... I will do my best, whatever in my capacity I can to follow up so that whatever recommendations came from the coroner's review, that gets implemented, and at least no other child ever goes through this, and no other mother ever faces what I have been through."
The coroner's office called on the Ministry of Education to do several things including "implement standardized documentation requirements" through a policy directive so that school staff are required to record all decisions or interactions with students and families related to student conflicts or alleged bullying.
It also said school boards should have protocols for doing suicide risk assessments after a bullying report or incident and immediately notify parents of any conflict that involves their child before an investigation or any other action is taken.
"No parent should have to bury their child. The story of young Arka is tragic and a reminder of the trauma children can face, be it in school, at home, or in the community," said Caitlin Clark, Education Minister Stephen Lecce's spokesperson. "The ministry will review the recommendations within the report, and recommit ourselves to protecting children by countering all forms of bullying and discrimination and continuing to enhance mental health supports for students in need."
The coroner's office asked child welfare agencies to "implement a practice standard for conducting suicide risk assessments for any young persons with an open file who are known or believed to have been impacted by incident(s) of bullying."
It also said these agencies should review protocols to ensure staff can identify if a family has an open file and provide them with support, regardless of whether it falls within their mandate. The report said Mukherjee contacted an agency seeking support for bullying and the response was a "missed opportunity to look into the needs further and explore ways the agency could have supported the family."
Jayme Allen, press secretary for the Associate Minister of Children and Women’s Issues Jill Dunlop, thanked the coroner's office for its report.
"The death of any youth is a tragedy, including those impacted by the child welfare system. Our government has been very clear that bullying, discrimination, harassment in all of its forms is unacceptable. A core focus of child welfare redesign is to improve cross-sector collaboration and communication to promote better outcomes for children, youth and families," Allen said. "As we review the report’s recommendations, we will continue to work closely with partners in the child welfare, social services, health and education sectors to help ensure that children and youth have access to the supports they need, when and where they need them."
"They are very significant," said Mukherjee of the recommendations. "If they really get implemented a lot ... a lot of things will get changed completely."
When Cheyanne Ratnam, co-founder and president of the Ontario Children’s Advancement Coalition (OCAC), heard about Chakraborty's story in 2019, she reached out to Mukherjee's lawyer at the time in an attempt to connect with the mother who she thought might need support in advocating for justice.
They met at a coffee shop in downtown Toronto.
"I was just floored that, first of all, the outcome of Arka because ... not just to me, to a lot of people this is systemic failure on a bunch of systems, not just one system in one sector," said Ratnam. She soon brought in Irwin Elman, Ontario's former child advocate whose position had been terminated by the Progressive Conservative government by then.
They supported Mukherjee to contact the Toronto District School Board (TDSB), the Toronto Police Service and ultimately connect with the coroner's office. In fact, both Mukherjee and family friend Avishek Karmakar said their experience shows why the province should reinstate the child advocate's office.
"I think for us the journey would have been a bit ... easier, because clearly there was a lack of guidance," said Karmakar.
"Prior to the coroner’s office, Durba didn’t feel like she was being heard, she didn’t feel like Arka was being respected as this young person who passed away and that his story of being bullied was being hidden and not being heard," said Ratnam.
Ratnam said she agrees with the coroner's recommendations and that the report "will provide some space for Durba to process and heal."
"The overarching theme for me is that no child should be failed by anybody especially the systems that are engaged with that child and so we need to systemically do better in order to prevent another Arka from passing away and we need to do better to build safer communities for children and families so that this doesn’t happen again," she said, adding that there's often a disconnect between culture and the education system and that school boards need to engage more with the ethnic communities that make up their student population to" understand the nuances of those cultures" and people's experiences, while being "more trauma-informed."
Elman said there is "so much to learn from this situation" including learning more about newcomer children, how to solve student conflict and bullying or what to do when the child protection system drops a case.
"How does that little boy end up dead and what could we do to have prevented that?" he asked.
"Finally there’s a report that in a way vindicates what the mom has been saying: 'My son was a great kid, my son wasn’t served well by his systems that were meant to support him,'" said Elman. "Now it’s time for people to read that report, accept the recommendations made to them and act on them."
He pointed to one recommendation in particular that the coroner's office made to itself: "When non-natural deaths occur which may be related to circumstances connected to the education system, e.g. the young person’s recent experiences in the school setting, the Regional Supervising Coroner should request the involved school board to conduct an internal organizational review, and this review may be used to inform the coroner’s investigation."
In its explanation, the coroner's office said the boy's death followed a week of "contentious incidents" at school and that the sudden death "presents an opportunity for those primarily responsible for providing service to them to explore and reflect on the circumstances and interactions leading up to the death from fact-finding and lessons learned perspectives."
"Information confirmed by both the young person’s family and representatives of the involved school board indicated that although the school board had communicated that an investigation of sorts would take place following the death, this did not occur and therefore there is no documentation (summary, report, notes, etc.) indicating what was done, if anything, to verify and learn from this unfortunate situation," the report stated.
"That's really important," said Elman of the recommendation. "It’s outrageous that the coroner had to make that recommendation to himself so he can do it, but I’m grateful to him for making that recommendation," he added, arguing that this should fall within the education minister's purview.
Karmakar also highlighted this recommendation as an important one.
"When Arka came to this country, apart from the home the only other institution where he was seeking his console, his comfort or his mental or physical security was school, and clearly the school failed to provide him that," he said.
The chief coroner's office said this recommendation has "already been communicated to coroners across the province."
Mukherjee's MPP, Jill Andrew, wrote a letter to Lecce in March asking that he support or initiate an inquiry into Chakraborty's death through his ministry if the TDSB did not.
In a May 20 response, Lecce said he was made aware that the coroner's office and the Toronto police conducted investigations and that school board staff "continue to communicate with Ms. Mukherjee."
"Neither I as Minister nor ministry staff have the authority to intervene in disputes between school boards and individual students or parents for the purpose of directing a course of action," he said. Saying the province is a "leader in bullying awareness and prevention," Lecce also acknowledged that more needs to be done and that "the system failed Ms. Mukherjee and her son."
Andrew said she agrees with all of the recommendations in the report, which captured "the number of missed opportunities ... where there could have been more support for Arka, more support for Durba, more support even for the ... school staff."
"But I also read the report with great sadness and frustration and anger, because I wonder if these gaps didn't exist might Arka still have been here," the NDP MPP said.
To tackle racism and cultural bias connected to bullying, the report asked boards to connect with "cultural allies by engaging community agencies with expertise that can offer front-line staff and decision-makers with culturally relevant information so that a young person’s experience can be a culturally safe experience."
The coroner's office also suggested boards train staff on the "cultural context of newcomers" and the complexities of bullying, and that social workers receive "trauma-informed training."
TDSB spokesperson Ryan Bird said board staff would need time to review the coroner's recommendations.
"We look forward to being able to work through the recommendations to improve our practices to ensure that we’re as responsive and supportive as possible to families who experience tragic incidents such as this," said Bird. "Once staff have had the opportunity to review, we’ll be a in better position to comment on the recommendations. The TDSB reviewed all available information with regard to Arka’s tragic passing and provided the parent with information regarding school-related incidents that involved her child."