A Victoria coroner's jury examining the tragic 2010 death of Campbell River teenager Hayden Kozeletski has called for suicide awareness training for high school counsellors and risk assessments for emergency patients showing suicidal symptoms.
The jury made a total of 23 recommendations to several agencies after hearing five days of evidence arising from the teenager's suicide a year ago. Sixteen year old Hayden hanged herself on a beach in Cadboro Bay after walking away from the Ledger House Youth Psychiatric Centre.
Coroner's counsel John Orr says the inquest became "a fairly extensive review of the whole system."
Kozeletski disappeared from Ledger House on Dec. 19, 2010, after returning from a weekend visit to her Campbell River home. Her father, Phil, found her dead about two hours later near the beach on the grounds of the Queen Alexandra Centre for Children's Health where Ledger House is located.
The jury learned that the final months of Kozeletski's life were filled with depression, anxiety and panic attacks, and that the troubled teen made repeated visits to the emergency ward.
Hayden's mom, Barb Kozeletski, told the inquest she felt overwhelmed and angry when she tried to get medical help for her daughter. She said Hayden changed from an amazing child into an anxious, panicked teenager.
The inquest heard that Hayden became increasingly depressed in the fall of last year and made repeated visits to the emergency ward at Campbell River General Hospital.
In late October, Hayden was admitted to Ledger House and was to be discharged Dec. 17, but the plan was postponed because of the despair she was feeling. Kozeletski testified that she was told abruptly by Ledger House staff at a meeting on Dec. 16 that Hayden did not want to go home. She testified that she felt patronized and left the meeting in tears.
Kozeletski found her daughter, crying in the bathtub. She recalled Hayden saying: "I'd be better off dead. I just wreck everything."
"And I said to her, 'Every day that you breathe is a good day. If this is what you need, this is what we need to do.'"
Kozeletski, who took her daughter home that night. Still is distress Hayden went to the hospital where she was given medication, Ativan, and plans were made to send her back to Ledger House. Kozeletski said the atmosphere at Ledger House was cold when she and Phil took Hayden back. As they left, Hayden slid down the wall and looked up at her parents in defeat.
"We kissed her goodbye and told her we'd see her in a couple of days," Kozeletski testified. Hayden disappeared just after 5 p.m. and staff searched the building and the grounds for her.
The coroner's jury listened to the non-emergency call placed by Megan Hadley, the nurse in charge of the youth psychiatric facility at Queen Alexandra Centre for Children's Health, to Saanich police at 5:36 p.m. that night. The call was classified as routine and placed in a holding queue to be dispatched when an officer became available.
The call was still holding more than 90 minutes later when Hayden's dad found his daughter dead on the beach. He and Barb had been driving through Ladysmith when they received a call from Hadley that Hayden had disappeared. They arrived at Ledger House before police did.
Saanich police admitted this was "clearly a case of miscommunication." The police would have responded immediately to Ledger House on Dec. 19 if they'd been told a suicidal patient was missing, Sgt. Tyra Reid told the inquest.
One of the jury recommendations is that staff should be thoroughly familiar with the grounds as well as the building layout.
The jury recommended that the Ministry of Education should have ongoing suicide awareness training for all middle and high school counsellors . And, the Ministry of Health has been advised that a standardized suicide risk assessment be conducted for all patients who arrive at an emergency ward showing signs of being suicidal.
Coroner's counsel Orr said the Coroner's Service will follow up with all of the named agencies to determine what steps will be taken in response to inquest findings.
Barb and Phil Kozeletski could not be reached for comment.