Inquest into Dorchester school bus death of 13-year-old girl ends with 12 recommendations
Hailey Pierce died on April 13, 2022, from injuries she suffered when she jumped from moving bus
WARNING: This story contains distressing details
A New Brunswick coroner's jury examining the death of a 13-year-old girl who jumped from the emergency exit of her moving school bus in Dorchester two years ago has made 12 recommendations aimed at preventing similar deaths.
The jury took about five hours to deliberate at the Moncton courthouse Wednesday after hearing two days of testimony from 15 witnesses about the death of Hailey Pierce.
The teen was sitting with a friend at the back of the bus on her way home from Dorchester Consolidated School on April 12, 2022, when she suddenly stood up, opened the back door and jumped out, the inquest heard.
She was pronounced dead at the Moncton Hospital the next day at 11:24 a.m.
Coroner David Farrow determined her cause of death was a traumatic brain injury and ruled it a suicide.
The five-member jury reached the same conclusions and delivered recommendations dealing with school buses, mental health supports in schools, as well as the health-care system after hearing Hailey visited the emergency department for mental health issues nine times in the months leading up to her death, often because of suicidal thoughts.
The recommended changes for school buses include an additional adult seated at the back, assigned seating for students, based on needs and a mechanical interlock to prevent emergency doors from being opened while a bus is travelling over a certain speed limit.
The bus driver, Michael McIntyre, testified he was travelling about 53 kilometres an hour in an 80 km/h-zone at the time of the incident.
With respect to schools, the jury recommended more training for teachers or other professionals dealing with students with mental health issues, more supports within schools, such as additional resource teachers, guidance counselors, and educational assistants and alternative learning environments outside schools for students struggling with mental health and school-environment stress.
Hailey was assigned a child and youth counsellor through the province's integrated service program and had access to a quiet room at the school if she was having a conflict with another student or was feeling overwhelmed, school officials testified.
A single primary psychiatrist should be appointed to be in charge of a patient's medications, the jury said, and better resources should be available to mental health patients deemed high-risk, such as admittance to a psychiatric hospital for an extended period of time to monitor progress and reactions to medications, with follow-up appointments and evaluations by an assigned psychiatrist.
Hailey was taking up to four different medications at one point — some prescribed by her regular psychiatrist, while two other psychiatrists on-call at the ER prescribed other drugs or changed doses. In December 2021, when she was admitted to pediatric intensive care for four days due to fainting spells, a pediatrician took her off her psychiatric medications to determine if they were the possible cause.
There should be separate, more private and calm areas within ERs for mental health patients waiting to be seen, better communication between Horizon and Vitalité regarding patients' medical history, and a more proactive approach among professionals dealing with mental health patients to identify changes and potential gaps in their care, the jury said.
Amelie Comeau, clinical lead nurse at Moncton Hospital addictions and mental health program, testified her position and the team she leads were introduced in early 2022 to better help people who come to the emergency room with a mental health problem.
There are three dedicated rooms in the ER for people with mental health concerns, team nurses can consult directly with a psychiatrist without having to go through an ER doctor first, which saves time, and they follow up with community partners about patients' visits, she said.
In addition, the jury recommended "sufficient support" to assist parents or guardians dealing with mental health issues within their family.
Hailey's mother and other family members who sat in the front row throughout the three-day inquest declined to speak to the media.
Sexual assault not considered relevant
On Tuesday, when Jennifer Little, Horizon's chief nursing information officer, detailed each of Hailey's ER visits for the jury, she said the teen was transported by ambulance on Feb. 15 and disclosed to paramedics that she had been sexually assaulted.
The jury asked at the time for more information. Little said she didn't have the full file, only notes indicating, "patient told paramedics that she had mental health issues since a young age due to a sexual assault [and] that the last two weeks were worse with thoughts of suicide."
None of the recommendations dealt with sexual assault.
Asked for more information about the sexual assault following the proceedings, deputy chief coroner Michael Johnston had little to say.
"I'm not really able to comment any further on that. It was explored to the level that it was thought that it was needed for the purpose of the inquest," he said.
Agencies have 6 months to respond
Johnston told reporters he's pleased with the jury's comprehensive recommendations and believes they'll help prevent similar deaths.
"They did a good job at making some solid recommendations today that I support. And I didn't feel I had anything to add at this point," he said.
Johnston will forward the recommendations to the relevant agencies, which will have about six months to respond.
"Whether they'll be possible or not will really be up to the agencies to determine if it fits within their mandate and within their current safety standards."
He noted they are recommendations, not orders. But their responses will be published in the annual coroner's report. "That's the limit of our authority."
Still, "a number" of recommendations from previous inquests have been implemented, according to Johnston. "It's definitely something that we don't do for for no reason. We believe in the process and believe that it will help."
Horizon review prompted recommendations, changes
On Tuesday, the jury heard that Horizon Health Network came up with six recommendations for improvements, based on a quality process review conducted after Hailey's death.
Such reviews are done any time a patient who received mental health care in the previous six months dies, said Little, the former regional director of child and youth services for addictions and mental health, who co-led the review.
"We identify any potential process or system area that can be improved upon," she said.
Several people who interacted with the teen reviewed her medical reports together to come up with the recommendations, said Little. The recommendations included asking Horizon to:
- Explore the option to integrate standardized suicide risk-assessments into the emergency department triage protocol.
- Investigate opportunities to flag "high-risk" mental health clients when presenting and registered in the emergency department, such as previous suicide attempts or self-harming.
- Investigate opportunities for continuing education for all staff and external partners, such as Ambulance New Brunswick) regarding duty to report for child protection services.
- Review emergency department guidelines on after-hours mental health services.
- Engage all stakeholders and partners, such as school administrators and private counsellors, in the post-suicide review process.
Horizon has implemented all six, but the third one is considered only partially complete, as the regional health network can't dictate what external partners, such as Ambulance New Brunswick, do.