Nfld. & Labrador

Missed opportunities, gaps in care: Child advocate examines youth's suicide

A report released Friday by the provincial child and youth advocate looks at systemic failures in the case of a young person who died by suicide.

Report examines gaps in service after youth died while living in group home

Jacqueline Lake Kavanagh, the province's watchdog for youth issues, released a report Friday looking at how care systems can help young people with complex mental health needs. (Office of the Child and Youth Advocate)

Jane was 14 when the Department of Children, Seniors and Social Development first entered her family home.

Shortly after her 18th birthday, Jane would no longer be alive.

The youth, who CBC will refer to as Jane but whose gender and identity is not known, had been a victim of sexual abuse by her father. She was placed in care, and lived in nine locations before she died by suicide while living in a group home.

The province's child and youth advocate examined Jane's case closely in a report, released Friday, that recommends changes to remove barriers for young people requiring mental health support.

The report, A Soft Place to Land: Lessons for Client-Centered Careidentified multiple gaps and missed opportunities in how Jane received help.

Advocate Jacqueline Lake Kavanagh said although Jane's case was complex, the system could have worked better for her. Instead, she encountered rejections and delays.

"When young people are not stable enough emotionally to engage, it's really important to stay with them," Lake Kavanagh said.

"What we saw in this case was that it was the needs of the system, sometimes, that seemed to prevail."

She noted the role of trauma in young people interacting with social and mental health services, and encouraged input from those patients to be taken seriously.

"Thoughtfully incorporating the voices of young people into all planning processes involving them must be a priority for all service providers," Lake Kavanagh wrote. "If this does not happen, significant barriers will impede successful outcomes for the young people seeking help in Newfoundland and Labrador."

The report outlines multiple instances in which Jane's requests were ignored.

It also looked how different types of services either declined Jane's case or put her on a waiting list.

"Young people with complex lives and histories often don't subscribe to a 'one size fits all' menu," she said. "They do not always present to the system as the perfect client. Services need to be flexible, able to meet the youth where they are, and able to adjust with the changing dynamics."

Role of trauma

Lake Kavanagh endorsed "trauma-informed services" in cases like Jane's, such as more one-on-one therapy, peer support, and more psychiatric supervision. She also suggested enhanced skills training for those supplying care, but did not detail what that training might involve.

She also pointed to a months-long gap in services when Jane turned 18.

As a minor, Jane had child psychiatric services, but upon aging out of the system — despite remaining under care in a group home — she was placed on an adult services waiting list.

She remained on that list for nine months until she died.

"The lengthy wait and the uncertainty of the timing of access to the adult system were sources of stress, considering this young person's trauma history," Kavanagh said.

Jane, diagnosed with borderline personality disorder, depression, substance use disorder, ADHD and dealing with childhood trauma — the effects of which include an inability to regulate emotion — made repeated emergency room visits.

She was admitted 26 times in the two years before her death for overdoses and thoughts of suicide. 

Lake Kavanagh said her investigation revealed varying levels of care for suicidal youths who have been admitted to emergency rooms, but did not elaborate.

She pointed to multiple gaps in care and a lack of access to programs in Jane's case.

"While various services were sought, they were frequently met with eligibility restrictions such as age, wait-lists, and suitability, which prevented the youth from receiving the care that was desperately needed," she said.

The child and youth advocate is an independent officer who reports to the provincial government. Recommendations from the officer are not binding.

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