Inquest into Carleton student's suicide calls for better monitoring

A coroner's jury in Ottawa says Jason Renato Simon should have been more closely tracked by health professionals after he told them he was suicidal.

Jason Renato Simon was treated by doctors, social workers before taking his own life

Jason Renato Simon is seen here in a picture that was posted by his mother on a social media memorial. Simon died of suicide in 2016, and a coroner's jury has now issued its recommendations on how to prevent similar deaths. (Supplied)

A coroner's jury in Ottawa says Jason Renato Simon should have been more closely tracked by health professionals after he told them he was suicidal.  

That was one of 37 recommendations made by the five-person jury Friday into the suicide of the 20-year-old, who was studying criminology at Carleton University at the time of his death.

Simon, who was also a reservist in the Canadian Armed Forces, was found dead in his home near the St. Laurent Shopping Centre on Feb. 15, 2016.  

Over a 28-day period leading up to his death, Simon experienced a rapid onset of depression, extreme emotional behaviour and suicidal thoughts.

He sought help from 10 heath professionals, including psychiatrists, social workers and police.  He was also seen by experts at Kingston General Hospital, the Montfort and Ottawa hospitals — but as quickly as the symptoms came on, they would disappear, and he would be released from their care.

Shorten treatment wait lists

The inquest, which began Jan. 22, was tasked with examining the circumstances that led to Simon's suicide and making recommendations to prevent similar deaths.

Several psychiatrists testified at the inquest they suspected Simon had borderline personality disorder, a condition with symptoms that include inappropriate emotional reactions, a distorted self-image and intense, highly changeable moods.  

A majority of those with the disorder are prone to suicidal behaviour.  

However, considering the short timeframe during which Simon displayed symptoms, psychiatrists couldn't make a definitive diagnosis.  

The treatment for the disorder, called dialectic behaviour therapy (DBT), was only offered in a limited way at the time of Simon's death, with a wait list of more than a year.

The jury recommended hospitals or community-based services should be given enough funding to offer full DBT in cases where it's deemed appropriate, and that waiting times for the treatment shouldn't exceed three months.

Margit and Attila Simon are pleased with the jury's recommendations into suicide of their 20-year-old son. (Laurie Fagan/CBC)

Hospitals need 'suicide risk assessments'

The jury also said hospitals should be funded to create a short-stay observation unit next to their emergency departments so that staff can provide "careful suicide risk assessments."

Simon's parents, Margit and Attila Simon, who have two other children, were happy with the jury's recommendations.

"Everything we wanted in it is there, and more so, we are really pleased with the jury's work," said Margit Simon 

She said if her son had a case management officer right from the beginning to help him navigate the mental health system, the outcome might have been different.  

"He went from one hospital where he was admitted, then let go, and then went to another hospital. But they didn't know about the previous one, so everyone treated him life a first-time patient," she said.

I will make phone calls  I'm not going to let it go.- Margit Simon

His father Attila called the inquest "a hard two weeks," but said it was worth it.

"We learned lots of new things about Jason's illness that we didn't even know about, and how he was struggling," he said.

The jury also recommended implementing a protocol for sharing relevant mental health care information between universities and hospitals, with the consent of the patient.

Simon's parents both said they don't want their son's death to be in vain. Margit Simon said she would be contacting government ministries, universities and hospitals to make sure they were aware of the recommendations.

"I will make phone calls  I'm not going to let it go, because if you don't follow up, it will get lost," she said.

"And we don't want that to happen."