Final coroner's report details 16-year-old's spiral into drug use

A B.C.coroner has released a final report into the death of 16-year-old Elliot Eurchuk, endorsing inquest recommendations that there be better detection and care for young people struggling with substance use and mental health issues.

In the report released Monday, presiding coroner Michael Egilsonwrote a disturbingand detailed summary of Elliot's final years, drawing from evidence presented to the coroner's inquest in June 2019.

The teenwas found unresponsive by his mother in his bedroom inOak Bay, B.C., on April 20, 2018. His overdose death was ruled accidental.

Paramedics found illicit drug paraphernalia and used naloxone capsules near his body. A toxicologist later determined that Eurchukhad ingested fentanyl at lethal levels, along with cocaine, heroin and methamphetamine.

A pathologist concluded that Eurchukdied as aresult of mixed intoxication, which led to a heart attack.

Sports injuries led to opioid prescriptions

Egilson's report noted that Elliot loved rugby, soccer and boxing, but had ahistory of painful injuries. He had suffered two concussions by Grade 9.

In 2016, he injured his shoulder wrestling. According to the report, theteen obtained Dilaudid, a brand of the opioid hydromorphone, from a fellow student. After that, Elliot's drug use escalated.

The report said that in November 2016,his motherfound a bag of drugs in his room, some of which appeared to be from her dental practice.

Elliot then fractured his jaw while playing soccer, and wasprescribed hydromorphone for pain management. Later he was also prescribed Tramacet, a combination of acetaminophen and the opioid-like Tramadol, the coroner wrote.

In September 2017,Eurchukwas suspended from Oak Bay High School for allegedly providing drugs to other students, the report said. A principal's review committee placed himin Mount Douglas Secondary School in nearby Saanich.

During this time he wasprescribed the opioidoxycodone and more Tramacet for his pain, the coroner wrote.

Classmates in Grade 11 at Mount Douglasreported Elliot was using opioids every few days and was buying heroin off the dark web, the report said, adding thatElliot wanted to go back to Oak Bay High School and felt forced into counselling.

A drug screening came back positive in November 2017, and his parents wereaware, the coroner wrote.

'He wished he had died'

In February 2018 he was admitted to Victoria General Hospital with aserious infection. While on a hospital pass he tookfentanyl and cocaine and suffered a cardiac arrest back inhospital. He was revived with naloxone.

"Elliot is reported to have said that he wished he had died and that if he was put in a locked facility, he would become the worst drug addict imaginable or he would kill himself," Egilsonwrote.

Egilson noted that Elliot did not want doctors or counsellors sharing medical information with his parents.

Psychiatric assessments found that Elliot was quiet, reserved and forthright about drug use. The psychiatrist was concerned about his drug use and family conflict at home. But he wasn't deemed suicidal, so he was released with a harm-reduction plan and supports in place for the family.

Last seen 'agitated and disoriented'

He was later readmitted under the Mental Health Act, but discharged again a week later.

A psychiatrist testified there were nogrounds to detain the teen for psychiatric reasons; he was describedas "pleasant" and "co-operative" and was not expressing thoughts of suicide.

In March 2018, Elliot ended up at the emergency room inSt. Paul's Hospital in Vancouver because of a "decreased state of consciousness," the coroner wrote. He was released after a few hours with no drug testing.

The day before he died, Elliot bought drugs that were more powerful than he usually consumed, according to his friends. He was last seen around 10 p.m. near Cattle Point in Victoria, where he was described as "agitated and disoriented."

Inquest recommendations endorsed

The recommendations made by the jury at the June 2019 coroner's inquest were intendedto prevent deaths similar to Elliot's. All of those recommendations have now been endorsed by a coroner.

The jury recommended better detection, treatment and transition plansfor youth struggling with mental health and substance use in schools. The lack of long-term substance abuse treatment for youth and its total absence on Vancouver Island was also flagged.