'It’s never really over, I still lost a child': Jury returns with recommendations in Lexi Daken inquest

The jury in the coroner’s inquest into the death of 16-year-old Lexi Daken have determined the New Brunswick teen died by suicide on Feb. 24, 2021.

The five jurors also made several recommendations, but before unveiling them, they said they agree with the existing recommendations that were presented by Horizon Health and encouraged the health authority to continue its work implementing those items.

They followed up with seven of their own:

• Educating youth and the public on current mental services that are available;
• Market mental health services and how to access them;
• Improve hospital communication with patients;
• Standardize patient discharge information into one form that can be given to a patient outlining all relevant information, like follow-up numbers, medications and diagnosis;
• Clerks confirm contact information with patients;
• Consistent and specific wording for the “contract for safety” that doctors ask from patients;
• A parent or legal guardian be present when that “contract for safety” is asked.

A “contract for safety” is when a practitioner asks a patient to agree they won’t harm him or herself. It was what the emergency room doctor asked Daken at least twice during her ER visit on Feb. 18, 2021.

After the recommendations were read, Daken’s father, Chris, told reporters he’s not sure the contract itself is the best practice.

“I guess from my point of view, is the safe contract a valuable tool for staff members or a patient to use? I kind of look at it as a burden off the shoulder of a doctor that they can have contract made,” he said. “So, if they discharge that person and they go home the next day and maybe die by suicide themselves, it's a verbal contract like how?”

Daken said he’d have to digest the recommendations, but he is hoping Horizon can provide more information on how the changes they say are already implemented have made a difference.

“It would still be nice to see some reports of wait times. Have they been short and how often are people being seen? And I guess it would be nice to have some clarification on that as opposed to, you know, just somebody saying that these are the changes we've made. So, kind of like some follow up,” he said.

In a statement, Horizon’s interim president and CEO Margaret Melanson said the network now has dedicated addiction and mental health collaborative care teams working in four regional emergency departments.

She also provided some insight into how their changes are working.

Between May and December of 2022, the number of children and youth waiting for therapy dropped by 367 people, because of their “one-at-a-time/single session therapy” for people who need urgent access to a clinician.

She said this marks a 72 per cent drop in the waitlist over seven months.

The jury also recommended positive signage within waiting rooms to reassure those who may be suffering from mental distress.

Daken says he and his family will continue fighting for other families to ensure they get the mental health services they deserve.

“It's never really over, I still lost a child,” he said. “But I'm happy that this process is done. And some recommendations have been made and, you know, hopefully more changes can be made and we don't have to be going through this in another two or three years for another child.”

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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.