Timothy Henderson did not appear to be receiving needed care, says N.W.T. coroner

The N.W.T.'s chief coroner did not blame the Northwest Territories mental health system for the death of Timothy Henderson in 2015, but she did say it appeared Henderson was not receiving needed mental health care.

According to Cathy Menard's report released on Wednesday, 19-year old Timothy Henderson died by suicide at home in Yellowknife on April 21, 2015. Henderson was discovered by a family member shortly after retreating to the garage where the musician "often went to play music and relax."   

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Efforts were made to resuscitate Henderson at Yellowknife's Stanton Territorial Hospital before being transported to the University of Alberta Hospital in Edmonton. Henderson was kept alive there until April 26, 2015, when life support was removed and Henderson was declared dead.

Henderson's mother and father both previously laid partial blame at the feet of the N.W.T. health care system which they said failed Henderson terribly.

High risk, support lacking

In her report, Menard said Henderson was at a high risk of suicide because of the impulsive nature of previous suicide attempts, and "clouded judgment" given the teenager's persistent substance abuse.

She stated that "an integrated treatment approach with thorough safety planning, careful psychiatric diagnosis and care, structured psychotherapy and addictions supports was required."

Instead of receiving that care and support, Henderson "did not appear to have sustained psychotherapeutic supports."

In February 2015, Henderson made multiple visits to the Edmonton University Hospital for mental health care, including a visit to self-report an attempted overdose on Ritalin. Henderson was studying music in the city.

The teen returned to Yellowknife to live with family in March. By April 8 Henderson had self-admitted to Stanton Territorial Hospital's inpatient psychiatric unit for "suicidal ideation and poor coping skills."

According to the report, Henderson's medications were adjusted slightly before being discharged on April 17, 2015. Henderson's discharge plan included follow-up visits with a local counsellor and family doctor. Records do not indicate if those appointments were kept.

Henderson was offered residential addictions treatment, but declined. The teenager was scheduled for a follow-up psychiatric appointment five-weeks later, but died before then.

Recommendations

"Timothy Henderson ... struggled with chronic suicidal ideation, social isolation, a lack of emotional coping skills and substance abuse disorders," Menard wrote.

In her comments and recommendations Menard said that Henderson's isolation worsened after moving from Yellowknife to a large centre where familiarity with ways to seek needed help may have been lacking.

To address this, Menard recommended the Department of Health and Department of Education better coordinate mental health support for individuals who need it if they are leaving the North for education opportunities elsewhere.

Menard also called on the Department of Health and Social Services to develop an "integrated" approach to treating mental health problems and substance addictions, particularly for youth as they transition out of pediatric care while dealing with depression and suicide attempts.

That approach would use multiple treatments, including: evidence-based psychotherapies, cognitive behavioural therapy, interpersonal psychotherapy and dialectic behaviour therapy. All of these techniques can be delivered by trained social workers, mental health nurses, psychologists or doctors, Menard said.

She also recommended the department work with communities to "develop explicit support for families" of those dealing with mental health issues.

"There has to be some supports because right now, in the current system, there doesn't appear to be any," Menard told the CBC.

"Any improvement or enhancement in this area would be greatly appreciated by families."

Menard said she hopes the territory's new Mental Health Act will address some of her concerns.

The act will come into effect this year.