No inquest into suicide of 12-year-old Chazz Petrella, chief coroner decides

No inquest will be held into the death of a 12-year-old Cobourg boy with behavioural problems who committed suicide at his home in August 2014, Ontario's office of the chief coroner has decided.

Lawyer for family of Chazz Petrella says decision is 'deeply disappointing'

Chazz Petrella was 10 in this photo. He took his life two years later. (CBC)

No inquest will be held into the death of a 12-year-old Cobourg boy with behavioural problems who committed suicide at his home in August 2014, Ontario's chief coroner has decided.

The parents of Chazz Petrella had asked for a review of a decision by a regional coroner last year not to hold an inquest. They had pushed for an inquest to explore the circumstances of their son's death to prevent similar tragedies. The family alleged there were gaps in his care.

At the time of Chazz's death, many different agencies were involved in his life. The night before he was found dead, his parents brought him twice to the emergency room of Northumberland Hills Hospital in Cobourg, but he was released both times.

Julie Kirkpatrick, a lawyer for the Petrella family, said Tuesday that the decision is extremely disappointing. She said she found out about it on Friday through an email from the chief coroner.

"It's deeply disappointing to the family, particularly given the time, effort and extreme patience that the family has shown while engaging with the chief coroner's office in the past two-and-a-half years," Kirkpatrick told CBC Toronto.
Chazz Petrella was diagnosed with mental illness when he was 10. Nine agencies and services had files on him but despite the care he received, he committed suicide shortly after he turned 12. (the fifth estate)

In a letter to the chief coroner dated Sunday, Kirkpatrick said the parents "feel that Ontario has missed a significant opportunity to truly learn from the cumulative systemic failures that led to Chazz's death."

Dr. Dirk Huyer, Ontario's chief coroner, wrote on Friday to Kirkpatrick that the July 2016 decision by Dr. Paul Dungey, a regional supervising coroner in Kingston, was reasonable.

"While an inquest is a public hearing, it is not a public inquiry to explore all aspects of the life and death of an individual," Huyer wrote.

Huyer said his decision not to hold an inquest was based on a number of factors, including reasons provided for the review, the coroner's investigation, expert and committee reports and an analysis of the original decision.

"This case has been thoroughly investigated. It is my opinion that there are no systemic public safety issues identified during the death investigation that are not already well known in the public realm and in the process of being addressed," he wrote.

Irwin Elman, Ontario's provincial advocate for children and youth, said Tuesday he is also disappointed by the decision not to hold an inquest.
Janet Ashby-Petrella, Chazz's mother, told CBC News that the number of children committing suicide in Canada is not dropping. She says an inquest into the gaps in her son's care would help other families access services for their children. (the fifth estate)

"To say that I am disappointed in this missed opportunity to improve the lives of children with mental health challenges in this province is a great understatement," Elman said in a news release. 

"The public has more than expressed an interest and desire to see children and youth in similar circumstances receive the supports they need to thrive and fulfill their potential."

Elman said the decision not to hold an inquest implies that the province is not interested in finding out if anything can be improved. He said it is as though the province is saying: "There is nothing to see here, move along."

"That services provided to Chazz were excellent, even as his family disagrees, and that discussions about changes to mental health services in Ontario can be done behind closed doors in downtown Toronto, are incorrect in my view," he said.

He said his office will explore what it can do, within its legislated mandate, to ensure the family is heard.
The family of Chazz Petrella said the boy never received a thorough psychiatric evaluation or diagnosis. (the fifth estate )

"We will connect with the family and listen, and I will tell them how truly sorry I am at this decision."

No treatment plan ever provided

Chazz, the youngest of five children, started to show problems with his attention span and aggression when he started school. His behaviour escalated as he got older. He would fly into a rage, break things and threaten to hurt himself and others.

The Petrellas say almost a dozen agencies were involved with Chazz in the last few years of his life. By the time he was 11-and-a-half, Chazz had been in and out of three schools, two residential facilities and a psychiatric crisis centre.

He was diagnosed with a mental illness and doctors tried several medications, but they never pinpointed an exact diagnosis or treatment plan.

In the winter of 2014, Chazz was placed at a privately run school that specializes in working with children with behavioural issues. He thrived, but his parents couldn't afford the annual tuition of $21,000.

One night that August, Chazz flew into another rage. In the morning, on Aug. 21, his father found him hanging from a tree outside the family home. He had turned 12 the month before.

With files from Michelle Cheung