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A fatality inquiry report into the death of a 15-year-old girl who died by suicide in an Edmonton group home says a previous recommendation to prevent similar deaths disappeared into “a bureaucratic black hole.”
Kyleigh Crier hanged herself in April 2014 while in the care of a Crossroads group home, operated by the non-profit agency E4C.
Thirteen years earlier, a judge had recommended that group homes and other residential facilities for youth should have breakaway bars in showers or closets.
Collapsible bars are designed to break if a person’s bodyweight is placed on them, preventing suicides. Crier’s group home was still not equipped with them.
The recommendation regarding collapsible rods “disappeared into a bureaucratic black home, only to reappear in the aftermath of (Crier’s) death,” wrote provincial court Judge Frederick MacDonald.
It appears that as long as a decade before Crier’s death, Crossroads had been advised to change the rods but the work was never done.
The judge found that, overall, Crier appeared to be stabilizing while at Crossroads but staff had no sense of her suicidal thoughts before her death.
“In my view, Crossroads provided (Crier) with a stability that had been absent from her life for many, many years.”
Youth need ‘suicide profile’ with their files
MacDonald made three main recommendations about how to prevent similar deaths from happening again, including:
- Caregivers must write a “direct and specific and detailed” suicide profile for every child being admitted to a placement or being moved from one placement to another.
The inquiry heard that when Crier was given a new case worker in May 2013, the worker did not know about her history of attempted suicide. When Crier moved into Crossroads, the worker did not forward any information about Crier’s prior mental health problems, including significant self-harm and a previous suicide attempt. “This is not withstanding there was ample information on file detailing both,” MacDonald wrote. Staff at Crossroads eventually learned about Crier’s mental health history through interactions with her.
- High-risk youth should not be assigned part-time case workers.
The inquiry heard that about a year before her death, Crier was transferred to a case worker who worked part-time. Crier often struggled to get in contact with the case worker, as did the Crossroads staff. MacDonald wrote that if “a case worker in the high-risk youth initiative is not available, youth should have a full-time case worker with training in working with high-risk youth.”
- Every facility for high-risk youth should review how to handle the placements of youth whose behaviours are particularly detrimental to others in the facility.
The inquiry heard that in the months before her death, Crier was threatened by another teenage girl at Crossroads, who was considered “high-risk and violent.” The other teenager was actively involved in the sex trade and meth use. Other teenage residents asked to be moved from Crossroads because of her presence. Crier was threatened by the youth and told staff she was scared of her. Despite concerns from some staff, the girl was not removed as “bed closure was (considered) a last resort.”
‘A very hard life’
In her 15 years of life, Crier bounced between foster homes, group homes, her mother’s home, and eventually Crossroads.
She suffered from substance abuse and mental illnesses including depression, psychotic disorder, and self-harming behaviours. She had consistently gone AWOL from group-care settings, and at times was reluctant to take medications for her mental illness.
But a case worker at her fatality inquiry described Crier as “a sweet girl who wanted a better life.” She loved her younger siblings, who she had at times acted as caregiver for.
“She loved, cared for and longed for the company of her brothers,” the fatality inquiry report stated.
Prior to arriving at Crossroads, Crier had twice been confined to a secure treatment facility as a precaution for her own safety.