The BC Coroners Service has released the report and recommendations of a Death Review Panel into child and youth suicide in British Columbia.

The panel, composed of experts from across the spectrum of child-serving agencies, made three recommendations, aimed at: maintaining and improving service co-ordination to children and youth; improving access to mental-health services for youth; increasing knowledge about youth suicide through enhanced data collection by the Coroners Service itself.

Chief Coroner Lisa Lapointe thanked the panel members for their commitment to the Death Review process and the prevention of child and youth suicide. "The collaborative nature of this process supports positive engagement and meaningful change."

The panel reviewed in aggregate the circumstances of 91 children and youth who died by suicide between 2008 and 2012. It concluded that child and youth suicide remains a highly complex phenomenon. Although there are a number of factors associated with increased risk of suicide, those factors were not found consistently across the children and youth who died. As such, panel members concluded there is no way of accurately predicting or identifying which young people are at the highest risk for suicide.

"While the panel have concluded that there is no one-size-fits-all solution that will reduce or eliminate child and youth suicide, there are specific things we can be doing to move forward with prevention efforts," said Michael Egilson, director of the BC Coroners Service Child Death Review Unit and panel chair. "These include more proactive co-ordination of services, removing barriers to service access and engaging young people in the process. Ongoing commitment and implementation at the community level will be key."

The panel recommends the Coroners Service work on gaining further information on such issues as bullying, social media and sexual orientation when investigating the youth suicides that do occur.

Lapointe says the Coroners Service fully supports that recommendation. "The Coroners Service is now in the process of determining how to implement those suggestions most effectively," she said.

The full text of the report can be found at: http://www.pssg.gov.bc.ca/coroners/child-death-review/docs/death-review-panel-2008-2012.pdf

A backgrounder follows.

Contact:

Barb McLintock
Coroner, Strategic Programs
BC Coroners Service
250 356-9253 or 250 213-5020

BACKGROUNDER

TEXT OF RECOMMENDATIONS

RECOMMENDATION 1: Service Co-ordination

School districts continue to bring together key community partners involved in serving youth and families to develop community level risk assessment protocols in support of early intervention and prevention of harmful behaviours, including appropriate information sharing among agencies and proactive follow up with young people and their families.

BC provincial government and school districts continue to ensure local front line staff are provided with education on supporting the mental health and well being of children and youth.

RECOMMENDATION 2: Access to child and youth mental health services

As part of its child and youth mental health services review and partnership with Ministry of Health (MoH) and Health Authorities, the Ministry of Children and Family Development (MCFD):

• Map MCFD and contracted agency mental health services and service levels across the province and make the information easily accessible and publicly available;
• Identify and address barriers to accessing mental health services, inclulding the perspective of what young people identify as barriers to services;
• Identify and address barriers to transitioning between community mental health and acute hospital services; and
• Identify and address barriers to transitioning from child and youth to adult mental health services.

RECOMMENDATION 3: BC Coroners Service practice

The BCCS further contributes to the knowledge base of children and youth suicide by:

• Proactively providing child death Coroners Reports, when deemed appropriate, to stakeholders for educational purposes;
• On a trial basis, requesting toxicological analysis and Pharmanet records for all child and youth suicides;
• Reviewing investigative questions with respect to a young person's sexual orientation to ensure the information is being gathered consistently;
• Reviewing investigative questions with respect to bullying to see if additional light can be shed on this issue;
• Ensuring a young person's use of social media is investigated as an information source for all child and youth suicides.

PARTICIPATING MEMBERS ON THE DEATH REVIEW PANEL

• Dr. Evan Adams - Office of the Provincial Health Officer
• July Adams - Ministry of Health
• Dr. Kelly Barnard - BC Coroners Service
• Michelle DeGroot - First Nations Health Authority (on behalf of Marilyn Oda)
• Brendan Fitzpatrick - Royal Canadian Mounted Police (R.C.M.P.)
• Shelley Green - Principals and Vice Principals Association
• John Greschner - BC Representative for Children and Youth
• Dr. Jean Hlady - BC Children's Hospital
• Jennifer McCrea - Ministry of Education (On behalf of Sherri Mohoruk)
• Dr. Shannon McDonald - Ministry of Health
• Dr. Ian Pike - BC Injury Research and Prevention Unit
• Dr. Elizabeth Saewyc - School of Nursing, University of British Columbia
• Alex Scheiber - Ministry of Children and Family Development
• Dr. Jim Thorsteinson - BC College of Family Physicians
• Dr. Jennifer White - School of Child and Youth Care, University of Victoria

MICHAEL EGILSON, chair of the Death Review Panel

Michael Egilson, who chaired the Death Review Panel into Child and Youth Suicide, joined the BC Coroners Service in 2012 as chair of the Child Death Review Unit.

Before joining the Coroners Service, he had worked in the public sector for more than 25 years, with a large proportion of his work devoted to improving the health and well-being of children and youth. Among other roles, he served as:

• Manager of child and youth health, Population and Public Health Division, Ministry of Health;
• Associate child and youth officer for the Child and Youth Officer for BC.
• Program manager for the Children's Commission.
• Program manager for Alcohol and Drug Services for the province, for both youth and adults.

He received his BA and Bachelor of Social Work from the University of Victoria and his Master of Arts in Social Welfare Policy from McMaster University.