Jury deliberating at Lexi Daken coroner’s inquest, recommendations expected

Lexi Daken was 16-years-old when she died by suicide on Feb. 24, 2021. (Source: Chipman Funeral Home)

Warning: This article contains references to suicide.

In the final day of testimony at the coroner’s inquest into the death of Lexi Daken, the jury heard from the health-care professionals who tried to save the New Brunswick teen’s life the morning she overdosed on medication.

The inquest also heard the recommendations at Horizon Health Network that were made to improve the treatment of those in mental distress after her death.

Daken was 16-years-old when she took her own life on Feb. 24, 2021.

But, six days before, she sought help from the Dr. Everett Chalmers Hospital in Fredericton, where she waited for more than eight hours with her guidance counsellor to see a psychiatrist. She never saw one.

Intensive care physician Dr. Zeeshan Aslam described a flurry of activity the morning of Feb. 24, 2021, with many health-care practitioners working to save Daken, including ICU and CCU staff and guidance from poison control in Halifax.

He said he started helping once Daken was moved to the intensive care unit from the emergency department. But, after several attempts, the teen died just before 11 am.

Another intensive care specialist who also worked on Daken that morning, Dr. Krishna Pulchan, testified on Tuesday that the teen’s case was a “very humbling experience for me.”

Saint John Regional Hospital pathologist Dr. Mohammed Hossein performed an autopsy on Daken on Feb. 25, and confirmed her cause of death was from drug toxicity.

Rachel Boehm took the stand next. Boehm is the executive regional director with Horizon Health’s addiction and mental health, but only took on that role after Daken’s death, in 2022.

She was involved with the case review that followed Daken’s death. Those reviews are done after a “significant” event or death occurs.

Boehm was asked about the recommendations that came from the review.

The first, to establish better communication between private and public providers, and share information that might be helpful for patient treatment. She said it wasn’t approved by the committee because it wasn’t “feasible,” to do it provincewide, but they can do it on an individual case-by-case basis.

The second was to have an education strategy for emergency room staff, to ensure they have skills in treating mental health patients and identifying risk. It was not approved, because it duplicated work that was already underway.

The third was to ensure information after a visit to the ER reaches health-care practitioners in the community - and if a practitioner is off for any reason, another clinician can take a over in urgent cases.

The fourth, to make sure all emergency room staff know and understand the capability of the mobile crisis unit, who can go to someone’s home, so staff can recommend them to patients.

The fifth and sixth included changes in the number of psychiatric staff present at the emergency department.

Prior to Daken's death, there was a psychiatric nurse on a consult basis for emergency room patients, but this individual worked on inpatient care most of the time.

“This service was somewhat hit and miss,” Boehm said.

The immediate action was to the mandate a psychiatric nurse be placed directly in the ER. She said that has since been improved further. Now there’s a dedicated team, including a social worker, licensed practical nurses, registered nurses and psychiatry professionals in the ER 24/7.

The aim is that patients suffering from mental distress experience a much shorter wait.

Another recommendation was to add a space for those with mental health concerns to go to, rather than wait in the general waiting room.

She said that was done quite quickly, and now all ERs across Horizon have dedicated, quiet spaces for those seeking mental health help.

Boehm also said they identified a need for a more standardized and inclusive suicide risk screening, including education for staff. They have adopted the “Columbia” system, a well-known screening tool all staff are now using.

She said they also identified the need to fast-track any high-risk referrals for child or youth so they’re seen as soon as possible.

Number 10 was to increase information sharing between care providers, like the emergency room physician to the psychiatrist in the community.

The last recommendation was to create education for all staff when it comes to treating youth with mental health needs, which she says was already underway.

One option that didn’t exist until after Daken’s death is a one-time, almost immediate appointment with a mental health professional at community clinics if a child or youth asks for that help.

This is the first time these recommendations have been spoken about publicly since the review was ordered in March 2021.

Boehm said there can still be a wait, especially if there’s a full waiting room, because each individual needs to be triaged in order for staff to know if someone is looking for mental health help.

Coroner Emily Caissy gave her instructions to the jury Wednesday morning, and they are now tasked with determining Daken’s manner of death - and if there are any recommendations they can give to improve the system and try to stop a similar death from happening again.

---

 

If you or someone you know is in crisis, here are some resources that are available in Canada.

 

Canada Suicide Prevention Helpline (1-833-456-4566)

 

Centre for Addiction and Mental Health (1 800 463-2338)

 

Crisis Services Canada (1-833-456-4566 or text 45645)

 

Kids Help Phone [phone])

 

If you need immediate assistance call 911 or go to the nearest hospital.