Suicide of Fredericton teen was preventable, provincial advocate finds
Long-awaited report makes 12 recommendations, including training for health-care workers
Lexi Daken's death was preventable, says a newly released report on the 16-year-old Fredericton girl's death.
"Having reviewed all the circumstances of Lexi's passing, we come to the regrettable but inescapable conclusion that this death, like many youth deaths from suicide could have been prevented," says the report from New Brunswick's child and youth advocate.
The report confirmed what Chris Daken has always maintained about his daughter's death — that with the proper help it would not have happened.
"I always believed that if Lexi got the help that she asked for that night … there would have been a different outcome." Daken said Wednesday.
Lexi Daken was a Grade 10 student at Leo Hayes High School in Fredericton. Her family began to notice problems last summer and tried to get her help. By November, she tried to take her own life.
In February, a guidance counsellor at her school noticed she was struggling and took her to the emergency department of the Dr. Everett Chalmers Hospital.
According to the report, Lexi was assessed by the triage nurse as being "urgent" and requiring "emergency intervention." Yet she only saw an ER physician, who repeatedly asked if she could keep herself safe at home. Lexi repeatedly answered that she could not.
Eventually, after hours spent in the hospital, Lexi finally replied, "Yeah, I think I can," and was sent home with a referral.
"On the following day (February 19) at 9 a.m., the ER physician's urgent psychiatrist referral was faxed to the Victoria Health Centre. This fax was then forwarded to Lexi's assigned ISD [Integrated Service Delivery] clinician and did not result in a psychiatry referral as intended.
She died by suicide on Feb. 24.
Her death sparked a public outcry and eventually led to promises by Health Minister Dorothy Shephard to fix the province's broken mental health care system. The report by the province's child and youth advocate was part of that review of services.
The report, entitled The Best We Have To Offer, was released Wednesday and makes several findings, foremost that health-care professionals don't have adequate mental health training.
"Our review found that DECH Emergency Department staff had little or no formal training and inadequate resources to support their working with mental health patients," said the report released Wednesday. "Even the ER psychiatric nurses we interviewed had not received specialized training; they gained their knowledge through experience working on the inpatient psychiatric ward.
"We were informed that some psychiatrists working on-call are reluctant to come in after midnight unless there is a serious mental health crisis situation. It was suggested that this may factor into the ER physician's willingness to consult them through the night. The fact that the ER physician left the decision up to Lexi of whether to consult the on-call psychiatrist is in our view unjustifiable."
Other findings include:
- A lack of standardized suicide risk assessment practices in emergency rooms.
- A chronic shortage of psychologists and psychiatrists.
- An over-reliance on crisis care and a lack of prevention services in community settings.
The authors say the role of the report was not to find fault.
"Nor is it our intention to lay blame at anyone's door in particular. Our review suggests that there is enough blame to go around in this matter for everyone to shoulder it," says the report.
The goal of the report is to make recommendations to improve the province's mental health system to try to prevent a similar death in future.
That was also the goal of going public with their family's painful story, said Chris Daken.
"My hope is that her death will lead to some positive change," he said after the report was released.
"I know other parents are still going to have to go through this, but if we can help alleviate as many parents from going through this, then yes, it's worth it,"
In presenting the report, Christian Whalen, the child, youth and seniors' deputy advocate, highlighted the need for better government accountability.
He said his department will closely monitor the progress of the 12 recommendations and report publicly every six months.
Whalen said his department needs more resources to keep track of the government's progress and to keep them "on track." He suggested resources comparable to the auditor general's department.
The recommendations also include:
- The appointment of a minister for children and youth supported by a secretariat, to ensure that all services for children and youth are integrated and collaborative.
- Training for all professionals working in child and youth mental health.
- The creation of a provincial strategy for child and youth rights.
- The incorporation of the United Nations Convention on the Rights of the Child into New Brunswick law.
- Development of an action plan for child and youth mental health and suicide prevention, with obligatory progress measurement.
- Follow-through on calls to action from the First Nations Advisory Committee established during this review.
- The creation of a youth-led child and youth health rights advisory council.
- Investments to address the shortage of mental health professionals in the province, and to make mental health services more broadly available.
More than 250 people took part in the public consultations and there were 4,000 completed surveys.
"Hillary, Jordan, Gabe, Samuel, Emily, Mona, Ashley, Lexi."
"These are only some of the names of young people whose loved ones we have met through this review whose lives were cut short by suicide," states the report.
"We have heard also from people who have attempted suicide and have healed and moved on, young people with recent experiences and old people who have carried the trauma of their childhoods with them for many years only to find peace late in life."
They also heard from families "worn down by the mental anguish brought on by having to help their child through their own journeys with mental illness."
"The tragic loss of Lexi Daken has led to immense pain for a great many people", said Norman Bossé, the child, youth and seniors' advocate, in a news release sent on Wednesday.
"I not only hope, but truly believe, that her passing will be the catalyst for imperative changes in the child and youth mental health system. The memory of Lexi gave power to this report. Her memory must now give power to the people who can make the changes that are so incredibly necessary."
Bossé did not attend the announcement on Wednesday. A department spokesperson said he could not attend because of "a personal medical matter."
In presenting the report, Whalen said children and youth have "a right to health and a right to life."
He said New Brunswick is "not meeting that standard in the area of suicide prevention and youth mental health services."
Whalen said the province should pay for more mental health treatment and cover it under Medicare.
And if the province can't afford Medicare-funded mental health services for everyone, "why not at least offer that to our children who are dying from these diseases and from suicide more than almost anything else?"
He said, "We're asking the province to push the envelope in this area by improving private insurance schemes. They always run out. Six counselling sessions really doesn't get you anywhere."
ERs need to change
In addition to better training for front-line health-care workers, Whalen said emergency rooms need to change. First, they have to do a better job triaging urgent psychiatric cases. He said ERs should also offer separate "safe, welcoming environments" for psychiatric patients.
And, he said, "We need to insist on avoiding practices that invite young patients to contract to safety," which is the phrase used in cases like Lexi's, where patients are sent home if they can agree to keep themselves safe there.
More professionals needed
Whalen said they heard from many people that "budget has not been the constraint."
"We have not run out of money for youth mental health services," he said.
Money has been set aside, but hasn't been spent on things like school psychologists, for example, so it goes back into consolidated revenue, said Whalen.
If you are in crisis or know someone who is, here is where to get help:
CHIMO hotline: 1-800-667-5005 / http://www.chimohelpline.ca
Kids Help Phone: 1-800-668-6868, Live Chat counselling at www.kidshelpphone.ca
Canada Suicide Prevention Service: 1-833-456-4566
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