A coroner’s jury has made 10 suggestions to attempt to stop deaths much like Lexi Daken’s.
The 16-year-old Fredericton-area lady died by suicide inside days of days of being turned away from the Dr. Everett Chalmers Hospital in February 2021.
Testimony on the inquest into Daken’s loss of life wrapped up Wednesday morning, and the jury of three girls and two males started deliberations earlier than midday.
By 3 p.m., they returned with their suggestions.
They started by endorsing 12 suggestions made by the Horizon Well being Community in March 2021 after an inner evaluate of Lexi’s loss of life, then added 10 of their very own.
A lot of the main target is on higher public schooling about psychological well being assets, together with making the knowledge extra available to the general public, utilizing brochures to assist with communication.
On Wednesday afternoon, Lexi’s father, Chris Daken, mentioned he’s relieved the method is over and hopes that Horizon Well being continues to make enhancements to how psychological well being care is delivered.
He mentioned his objective all alongside has been to make sure that no different household experiences what his has.
“It’s by no means actually over. I nonetheless misplaced a baby however I’m completely satisfied this course of is finished and a few suggestions have been made and hopefully extra modifications will be made and we don’t must be going by way of this in one other two or three years for one more youngster.”
Featured VideoThe Grade 10 scholar at Leo Hayes Excessive Faculty died by suicide in February 2021. Right now, the jury at a coroner’s inquest into her loss of life made 4 suggestions.
Lexi Daken was a Grade 10 scholar at Leo Hayes Excessive Faculty in Fredericton. She was a gifted athlete and a excessive achiever academically.
However as soon as COVID hit, with out sports activities, social actions and solely going to highschool each different day, Lexi’s psychological well being started to falter, her father, Chris Daken, testified on Tuesday.
He mentioned he didn’t notice how a lot she struggled till she tried to take her personal life in November 2020.
Turned away at emergency division
On Feb. 18, 2021, a steering counsellor at her college observed a deterioration in Lexi’s psychological well being and took her to the emergency division of the Dr. Everett Chalmers Hospital at lunchtime. She wasn’t seen by an emergency room physician till about 7:20 p.m.
After speaking with the physician and ready for the outcomes of blood assessments, the physician returned round 9 p.m. and requested if Lexi would “contract” along with her — to make a promise to not damage herself — and be protected at dwelling.
Lexi’s steering counsellor, Shelley Hansen, testified the physician mentioned, “Lexi, should you don’t contract with me, I’ll be pressured to name in a psychiatrist.”
Hansen mentioned she was “shocked” at using the phrase “drive.” She mentioned she noticed one thing change in Lexi’s face when she heard it.
Hansen mentioned she instructed the physician she believed Lexi actually wanted to see a psychiatrist. She mentioned she wasn’t comfy with Lexi going dwelling that night time, they usually even talked within the automobile as they sat within the car parking zone about returning to the emergency room and asking to web page the psychiatrist.
However they didn’t. Lexi went dwelling that night time and died by suicide on Feb. 24.
Lexi’s loss of life sparked public outcry and was the catalyst for a evaluate of psychological well being companies. That evaluate included a report launched in September 2021 by New Brunswick’s youngster and youth advocate, who concluded her loss of life might have been prevented.
16 witnesses over 3 days
The final of 16 witnesses at this week’s inquest in Fredericton was Rachel Boehm, Horizon Well being Community’s government regional director of addictions and psychological well being.
Boehm led the inquest by way of an inventory of 12 suggestions that had been made in March 2021 after an inner evaluate of the circumstances surrounding Lexi’s loss of life.
She mentioned the method includes a gathering of all the individuals who had been concerned and the objective is to give you system enhancements that would stop comparable incidents in future.
Primarily, defined Boehm, “what can we be taught to do higher subsequent time.”
Lots of the suggestions centred round improved coaching for emergency room workers. A few of the suggestions had been rejected as a result of they had been already underway, defined Boehm.
She mentioned a number of modifications had been made instantly following Lexi’s loss of life, together with higher coaching for ER workers in treating psychological well being issues and figuring out high-risk sufferers.
One of many largest modifications, mentioned Boehm, was the addition of a devoted psychological well being crew in emergency departments. She mentioned sufferers nonetheless have to attend to be triaged, however as soon as psychological well being issues are recognized, sufferers are diverted to a separate, quiet space the place they wait to be seen by a multidisciplinary crew of execs.
Boehm mentioned a niche was additionally recognized in transferring sufferers to community-based companies. Suggestions included making a standardized system for transferring sufferers, which incorporates steps to make sure sufferers don’t fall by way of the cracks.
Associated to that, Boehm mentioned, emergency room workers had been reminded concerning the cell disaster unit and the way it may be used. Equally, workers members had been reminded that “pressing” time slots had been at all times reserved for next-day referrals for psychological well being companies.
The group additionally urged establishing a standardized system for transferring sufferers from personal care to the general public system. Boehm mentioned the advice was rejected as a result of Horizon doesn’t have the authority over the personal system, and every career would have its personal regulatory physique.
Though rejected, Boehm mentioned the general public system can nonetheless attain out in particular person circumstances and make each effort to acquire permission to get personal counselling data.
She mentioned the switch of companies “is a time of threat,” and the purpose is to cut back the potential of gaps in service or being misplaced.
Summarizing the effectiveness of modifications which have been made since Lexi’s loss of life, Boehm mentioned psychological well being sufferers at the moment are seen by specifically educated intervention groups rather more shortly once they current at emergency departments.
Jury makes 10 suggestions
The jury’s suggestions targeted closely on schooling — higher educating the general public about assets out there and sufferers about what precisely is offered to them and preserving them knowledgeable by way of each step of the analysis and remedy levels.
They advocate:
- Growing consciousness and educating youth and the general public about what psychological well being companies can be found.
- Obtainable psychological well being companies needs to be marketed and knowledge needs to be simply accessible.
- The hospital ought to enhance communication with sufferers and brochures ought to define companies and make contact with data.
- A standardized affected person discharge data sheet needs to be given to sufferers with related medical data from their go to, akin to analysis, drugs and care plan.
- Hospital clerks ought to verify contact data with sufferers.
- The “contract for security,” an settlement between the affected person and health-care suppliers, ought to use constant and particular wording.
- A dad or mum or authorized guardian needs to be current and concerned with the “contract for security” if the affected person is a youth.
- Group psychological well being companies ought to specify the following follow-up appointment, with date and time.
- Signage within the ready room needs to be exhibited to reassure and help sufferers who’re ready.
- Further assets needs to be made out there for group psychological well being companies.
If you’re in disaster or know somebody who’s, right here is the place to get assist:
CHIMO hotline: 1-800-667-5005 / http://www.chimohelpline.ca
Children Assist Cellphone: 1-800-668-6868, Reside Chat counselling at www.kidshelpphone.ca
Canada Suicide Prevention Service: 1-833-456-4566