The DPJ could not prevent the suicide of a 17 year old particularly troubled that he himself had asked to be removed from the family and had already attempted suicide once.
In a recent report obtained by La Presse, the Coroner Renée Roussel, who investigated the death of the teenager, urges the government to provide as soon as a new procedure for employees of the child welfare services, which base their interventions on an old protocol of 15 who is “out of date”.
It also denounces the lack stakeholders training in the region of Bas-Saint-Laurent, where occurred the tragedy, and highlights serious communication problems between the staff of the DPJ and that of the health network, each cut behind his duty of confidentiality.
A difficult life
Louis was found dead in his apartment in Trois-Pistoles one afternoon in August 2013. He should have turned 18 two months later.
In the kitchen there were syringes and empty insulin cartridges everywhere. As for the convenience of those who were going to find him, the boy took out his health insurance card and hospital cards.
Louis, we chose to silence the family name to protect his siblings, was born in Belarus. It was adopted by a couple from Quebec at the age of 7 years. At home, it was very difficult, we told her father. The boy suffered from fetal alcohol syndrome, a severe attachment disorder and oppositional disorder and provocation. Diagnostics including its new parents were not informed before it examined in Canada. After three years of anger, tears, crises and many therapies, nothing was more. Louis himself has called the DPJ to ask to be placed. He was 10 years old.
“The fact that he wants to go, it was not easy. We were asked several questions about us. “Says the father of Louis.
But the boy was not well in the family life. It did not fit. He wanted to get better. According to the coroner, the parents were “at the extreme end of their resources.” They let their son hoping to see it flourish. Instead, he pressed.
His adolescence was marked by frequent moves between foster homes, rehabilitation centers and intermediate resources. He had difficulty in school. He had money problems and crime. He struggled to keep a job because of his anger. He refused to seek treatment for both its psychological problems for diabetes which he suffered.
In 2012, Louis tried to kill himself first in injecting a massive dose of insulin after consuming drugs and alcohol. He was living in an intermediate resource of the DPJ.
According to the investigation of the coroner, the seriousness of this suicide attempt would have been greatly underestimated. The many players who looked after Louis did not even have all been informed of the event. Employees of the DPJ and the health system have not shared their information because of their privacy policies.
“I have difficulty understanding how we did however have really become entangled with these rules if this is true for something as serious as suicide. “To question the coroner Renee Roussel.
After the attempt and hospitalization that followed, the teenager was not entrusted to psychosocial resources. Youth center stakeholders were left to themselves.
“The suicide attempt was not taken seriously enough and [was] underestimated by more than one professional to the health center and social services”, slice the coroner.
A year later, Louis lived in a supervised apartment to prepare for adult life. There he killed himself.
His family, who had kept in touch with the young man even though she had no right to it, do not understand what could have happened. “Louis was left behind, his father said. There are “protection” in Youth Protection. In his case, I do not see what that word is there. When someone leaves to himself, he will get in trouble. He was a good boy. It was endearing. Very endearing. ”
As part of his research, the coroner found that youth centers today still based their interventions on a suicide prevention protocol dating back to the early 2000. It “is based on the time of the knowledge that are now out of date. ” Work is underway to modernize, but new guidelines are awaited. She urged the Department of Health to accelerate the process. A spokeswoman tells us that the protocol should be modernized ready for winter.
The Integrated Centre for Health and Social Services of the Bas-Saint-Laurent, it claims to have taken note of all the recommendations of the Coroner to prevent such tragedy from happening again. The Executive Director of CISSS requested an action plan on the day it received the report, on 15 July. The new measures should be in place by September.
A difficult life
Louis was born in a poor district of a city of Belarus. His mother is 16 years old.
His biological mother dies. It is placed in an orphanage.
Louis was 7 years old when adopted by Quebec parents.
At 10, Louis is entrusted to the Youth Protection until his majority.
The boy began to suffer from type 1 diabetes.
He made his first suicide attempt.
The teenager left school.
August 26, 2013
The owner of the apartment Louis knocks on the door and gets no answer. The door is locked from the inside.
August 27, 2013
The young man is found dead in his apartment by police officers who come to force the door.
In March 2014, William Crépeau-Bonnier, 15, took his own life while staying in a youth center in the Laurentians. A judge of the Court of Quebec ordered he receive psychological treatment he was still waiting.
In March 2011, James Dassonville, 17, hanged himself in his bedroom Mont Saint Anthony Youth Centre of Montreal. He was supported by the DPJ from the age of 3 years. He suffered from mental health problems. Coroner Catherine Rudel-the Tessier found that the Youth Centre and educators had done their job