No documented suicide assessment for Cree teen who died in B.C. group home, review finds

A review done after the death of a Cree teen at his Abbotsford, B.C. group home found a failure to document suicide assessments and major delays in writing a treatment plan, a coroner's inquest heard Wednesday. 

The review by Child Welfare and Aboriginal Services was done after 17-year-old Traevon Desjarlais took his own life in September 2020. His body was found in the closet of his room four days after he was reported missing.

The review found that while the social worker for the teen was addressing Desjarlais' concerning behaviors around headbanging, and had outlined steps to ensure his safety – there were other missing pieces in his treatment plan.

“We did not find any documentation in the records that outlined what the suicide assessment was, or what the risk plan was, or who that was provided to,” said Tricia Meyers, acting executive director in the provincial office of the Child Welfare and Aboriginal Services branch. Despite this, she said the lack of documentation didn’t necessarily mean the assessment wasn’t done.

Meyers also said that an evidence-based treatment plan provided for the youth was not documented for four months after services began.

She also said there have been several other reviews done involving other children where important documentation also was not found.

Changes have been made since Desjarlais' death, according to Meyers, including ongoing training for workers and the introduction of a more standardized form for suicide risk assessment which is to be rolled out in the coming weeks.

The inquest also heard from James Wale, B.C.’s deputy director of child welfare for the Ministry of Children and Family Development.

He said a new short-term stabilization program is being piloted in B.C. next year.

“Short-term stabilization will be designed for youth with complex needs where the staff have clinical training, where there’s wrap-around support and where there’s a focus on working with the parents or relatives,” he explained.

Youth would stay in these homes for three to nine months, but the goal is to return youth to where they were before if at all possible, he said.

He also said his department is working on a new tier of family care homes for youth with higher needs. These homes will provide extra support and service and it's hoped they may allow a young person to stay in a family care home.

Wale said 70 per of children in care in B.C. are Indigenous.

“It’s a horrible tragedy that happened to Traevon,” he said, adding that his takeaway from the inquest is the importance of a child’s need to belong to their family, community and culture.

“That’s what I heard from the testimony, that Traevon felt alone, despite people being there for him,” Wale said.

He was the last witness at the inquest.

The coroner’s jury can not make findings of fault, but can make recommendations aimed at preventing similar deaths in the future.