Health-care providers testify as inquest begins into death of teenager Lexi Daken

WARNING: This story containsdetails about suicide.

A coroner's inquest began Monday morning into the death of 16-year-old Lexi Daken, who took her own life in February 2021, just days after being sent home from the Fredericton emergency department without receiving any mental health intervention.

A jury of three women and two men heard testimony from five witnesses on Monday all of them health-care providers.

Several of themtestified about asuicide attempt Lexi made a few months before she died.

In November 2020, Lexi swallowed dozens of pills, said Dr.AbayomiOtusajo, the psychiatrist who met with her at the Dr. Everett Chalmers Hospital once she was medically stable.

Lexi was taken by ambulance from her home in the early hours of Nov. 17. The paramedic, Edward Johnson, testified he asked Lexi about her "intent," and she said she had intended to "commit suicide." He also said she had been cutting her legs.

Registered nurse Terry-Lynn Gray told the inquest that Lexi was assessed as a Level 2 priority, meaning she was supposed to be seen within 15 minutes. She was seen by a doctor within five minutes.

Gray said Lexi was conscious and alert and her vital signs were good, despite the pills she had taken. Once she was medically cleared, she saw a psychiatrist at 8:45 a.m. and discharged by him at 9:50 a.m.

Otusajo said he diagnosed Lexi as havingborderline personality traits and major depressive disorder. He prescribed her anti-depressant medication and gave her a referral for community-based mental health services.

That referral initially went to the wrong group, explainedHaley Manuel, a registered nurse with the North Side Child and Youth Team.

Manuel said the referral was erroneously sent to the Oromocto teambased on the assumption that the Maugerville teen attended Oromocto High School.

There was also a delay in reaching the family. Phone calls made and messages left on Nov. 18, 19 and 20 were not returned, she said. The team mailed a letter on Nov. 20, Lexi's dadresponded to that, and an intake call was conducted on Dec. 18.

There was no explanation given about whether the team had the right phone number.

Lexi's case was flagged as a "high priority" and assigned to Manuel.

She explained to the inquest that they don't usually start counselling if someone is getting private counselling because they don't want to duplicate services.

On Jan. 7, Manuel said, she called Lexi's father and asked for an update. She said ChrisDaken told her that Lexi was still talking about suicide and that her sleep was "backwards."

On Feb. 10, Daken emailed Manuel and said they were finished private treatment and looking forward to meeting with her.

The plan was to start their sessions the following week at Leo Hayes, but since students were only going every other day because of COVID-19, Lexi was only in school the following Tuesday and Thursday.

Manuel said she was already booked on those days so intended to see her the following week, when Lexi was scheduled to attend school on Monday, Wednesday and Friday.

When Lexi was absent on Monday, Manuel called Chris Daken, who wasn't aware Lexi had slept in and missed school.

By then, Manuel was aware that Lexi had been taken to the Chalmers on Feb. 18 because of her deteriorating mental health.At that time, the plan was to see Lexi on Wednesday, Feb. 24.

Lexi died by suicide that morning.

Inquest aims to prevent similar deaths

The inquest is being held at the University of New Brunswick Law School in Fredericton and is scheduled to last five days.

The jury will also have an opportunity to make recommendations aimed at preventing deaths under similar circumstances.

Lexi's death sparked public outcry and was the catalyst for a review of mental health services. That review included a report released in September 2021 by New Brunswick's child and youth advocate, who concluded her death could have been prevented.

Lexi Daken was a Grade 10 student at Leo Hayes High School in Fredericton. Her family began to notice problems in the summer of 2020 and tried to get her help. By November, she had tried to take her own life.

In February 2021, a guidance counsellor at her school noticed she was struggling and took her to the emergency department of the Dr. Everett Chalmers Hospital.

Lexi was assessed by the triage nurse as being "urgent" and requiring "emergency intervention." Yet she only saw an ER physician, who repeatedly asked if she could keep herself safe at home. Lexi repeatedly answered that she could not.

After waiting about eight hours in hospital, Lexi finally replied, "Yeah, I think I can," and was sent home with a referral.

She died by suicide a week later.

An inquest is a formal court proceeding that allows for the public presentation of all evidence relating to a death. The New Brunswick Coroner Service is an independent fact-finding agency that does not make any finding of legal responsibility.

If you are in crisis or know someone who is, here is where to get help:

CHIMO hotline: 1-800-667-5005 / http://www.chimohelpline.ca

Kids Help Phone: 1-800-668-6868, Live Chat counselling at www.kidshelpphone.ca

Canada Suicide Prevention Service: 1-833-456-4566