A jury for the coroner’s inquisition into 16-year-old Lexi Daken’s 2021 death released its recommendations on Wednesday.
After three days of listening to witnesses, the jury found Daken’s cause of death to be suicide.
The jury recommended more education and marketing of available mental health services, a standardized discharge sheet for patients with information about their diagnosis and care plan, and specific wording around the “contract for safety,” an agreement between a doctor and a patient that the patient won’t kill themself, among other recommendations.
Daken died on Feb. 24, 2021, six days after she was discharged from Dr. Edward Chalmers Hospital, where she had come for mental health help. Her school guidance counsellor Shelley Hanson joined her during her Feb. 18 visit.
During the inquiry, she said Daken’s emergency room doctor, Rebecca McGinn, asked Daken to give a contract for safety. Hanson said McGinn told Daken if she didn’t say she was safe to go home, McGinn would be forced to contact a psychiatrist. Hanson said Daken hesitated before saying she was safe to go home. McGinn said she felt that Daken had a support system in place and didn’t have a reason to question Daken.
The jury also recommended that a parent or legal guardian be involved with the contract for safety when the patient is a minor.
Rachel Boehm, the executive regional director for addiction and mental health services for Horizon Health Network, which runs the hospital, also testified about changes the health authority has made since Daken’s death.
“The landscape has really changed,” she said.
After Daken’s death, the organization conducted a quality review. That review recommended standardizing the process for patients to access psychiatric nurses, adding a room for mental health assessments in the emergency room and fast-tracking referrals to child psychiatrists.
In a statement released after the inquiry, Horizon interim President and CEO Margaret Melanson said, “Horizon takes seriously and will be closely reviewing each of the recommendations which have been brought forward.”
Daken’s father, Chris Daken, said he doesn’t want what happened to Daken to happen to anyone else.
“Any changes that are made for the betterment of mental health has to be considered a positive,” he said.
Although the inquiry is over, his grief process will go on.
“It’s never really over. I still lost a child,” he said.
If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 911.
The Canadian Association for Suicide Prevention, Depression Hurts and Kids Help Phone 1-800-668-6868 — all offer ways for getting help if you, or someone you know, is suffering from mental health issues.
For a directory of support services in your area, visit the Canadian Association for Suicide Prevention.
Learn more about how to help someone in crisis on the Government of Canada website.
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