Quebec coroner calls for significant changes in how province protects teens with mental health problems
A Quebec coroner who investigated how a teenager ended up taking his own life alone inside a Montreal hotel room is calling for significant changes to how the province protects youth with mental health problems.
They are among recommendations Julie-Kim Godin made in a report of her recent probe into how the 16-year-old boy checked into a Montreal hotel and killed himself.
The coroner estimates the boy died on April 30, 2024. He checked into the hotel four days earlier and his body was found by hotel staff the day after he is believed to have died alone.
Because he was a minor, his name is redacted from the report made available to the public.
“Due to the intense emotional impact of a suicide involving a young person, it is crucial to state that my analysis is in no way intended to pass judgment or determine the criminal, civil, or moral responsibility of any individual or organization,” Godin wrote.
“The entire process aims to shed light, in the most compassionate way possible, on the circumstances surrounding the death of (the 16-year-old boy) and the contributing factors. This process also aims to formulate recommendations for the protection of human life and to prevent such a tragedy from recurring.”
The boy was part of a family that arrived in Canada during 2014. Godin’s report describes a tragedy where all the red flags were apparent to his family and health-care professionals, including the boy’s refusal to attend school. He was treated by institutions within Quebec’s health-care system, but was ignored by the youth protection system because it felt the boy was under the care of his parents. Godin describes the youth protection and the health-care system that treated him as having worked as “silos” that failed to communicate with each other.
Batshaw Youth and Family Centres, the organization responsible for Quebec’s anglophone population, closed the boy’s file days before he died.
Among her recommendations, Godin calls for the ministry of health and social services, which oversees youth protection, to “revise the concept of youth protection for young people who have experienced childhood trauma or who have behavioural or mental health disorders.”
She also recommends a revision of “the current legislative framework and available resources for youth protection and care when trauma or disorders compromise a child’s development” and to “improve practices and ensure interventions adapted to the realities of ethnocultural and marginalized communities.”
The coroner also calls for Santé Québec to “create a specialized, intersectoral and multidisciplinary youth crisis and intervention team, with a provincial scope, mandated to support treatment teams, intervene in the event of a major impasse with children presenting complex situations.”
Godin’s report details just how complex the teenager’s situation was.
“His medical records reveal that he was exposed to negative experiences during his childhood, including bullying, violence, and potentially traumatic situations. He also had a family history of psychiatric illness, constituting an additional vulnerability factor,” Godin wrote.
Changes in the boy’s behaviour were noticed near the end of his education in primary school. He was frequently absent and appeared to be socially isolated. This was before the COVID-19 pandemic arrived in Montreal.
“From 2020 onward, more significant changes in his mood, behaviour, and social relationships were observed. He completely stopped attending school and seeing his classmates. He became much more isolated, secretive, and solitary. He spent long hours alone in his room, mostly in front of screens,” the coroner noted.
“Clinically, he progressively developed depressive and anxious symptoms. Child psychiatric evaluations conducted in 2022 led to diagnostic impressions of severe anxiety disorder, social phobia, and behavioural disorder. Major depressive disorder, attention deficit hyperactivity disorder, learning disability, and autism spectrum disorder were also considered.”
Beginning in 2022, the boy exhibited suicidal thoughts and, on Aug. 6, 2022, he reported this to a suicide prevention service. Police were called in to intervene and the teen was hospitalized.
During 2023, his condition grew worse. The report descibes how he appeared to become obsessed with police work. He would confront police officers, record the interactions and post the videos on the internet. During July 2023, he was charged with a crime.
That same year, “several reports were made to the youth protection directorate.
“The ministry of education and the school service centre were aware of (how he had stopped going to school). They were also informed that (the teen) began working in 2022. Based on the medical certificates they had received, the ministry of education demonstrated tolerance and flexibility. However, they do not appear to have been fully aware of the persistent seriousness of the psychosocial issues and mental health problems, the difficulties encountered in the care pathway, or the reports filed with youth protection services,” the coroner wrote. “This fragmentation of information sharing between the different systems contributed to maintaining a concerning situation for nearly four years, without a concerted intervention to re-establish a structured educational framework.”
The report details what appears to be a crucial moment in the boy’s life. During the spring of 2022, reports were filed to youth protection that “highlighted several concerns regarding (the boy), the difficulties encountered, and the inability of the health-care system to assist (him) without the intervention of the youth protection services.
“A June 1, 2022, report was ultimately accepted in September 2022 for educational neglect and behavioural problems. However, based on the submitted file, (he) was not seen, and no structured intervention plan or measures were implemented. The file with youth protection services appeared to be at a standstill.”
“This situation is particularly concerning, given the important role of the youth protection services in child protection and the number of reports filed,” the coroner wrote.
“Furthermore, health-care professionals do not appear to have been consulted or involved. They even believed that youth protection was not involved. This situation illustrates the siloed approach between the two systems.”
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