Jail records suggest that for eight days prior to hanging herself in her cell at the Brandon jail, a 16-year-old girl wasn’t offered her prescribed medication for depression.
A nurse testified at an inquest that, as far as he could tell, prescriptions for anti-depressant, anti-psychotic and anti-anxiety medications weren’t filled and the drugs weren’t offered to the youth.
In addition — even though a jail intake assessment showed that she was on medication, and had a history of suicidal thoughts — there’s no record to show she was referred to psychiatric health services.
"Had you been the person who was doing this initial admission assessment and somebody presented … with this history and these types of medications, you would have made a referral to health psych services?" Dakota Ojibway Child and Family Services lawyer Dean Kropp asked.
"Yeah. It’s part of our protocol," replied Michael Briol, who worked as a nurse at the jail at the time of the girl’s death and was one of those who tried to revive her after she was found.
The girl died in hospital on Oct. 2, 2013, four days after corrections officers found her hanging in her cell within the Brandon Correctional Centre’s Juvenile Unit.
She’d arrived there on Sept. 20, 2013, and was held in remand custody for eight days, up until the time she was found hanging on Sept. 28.
The inquest — intended to produce recommendations aimed at preventing similar deaths — began in Brandon provincial court on Monday before Judge Shauna Hewitt-Michta.
DOCFS, Prairie Mountain Health, Manitoba Corrections, and Specialized Foster Homes have standing at the inquest, entitling their lawyers to ask witnesses questions.
The girl was a ward of DOCFS at the time of her death, and a resident of Specialized Foster Homes from Feb. 26, 2016, until she was jailed.
Her grandmother also has standing at the inquest. She heard testimony from corrections officers who described the effort to save her granddaughter’s life.
She also saw those efforts play out in video surveillance footage played for the court.
While asking one of the officers questions, she thanked him for trying to help.
"I’m sorry for your loss," Kyle Foubert replied.
Foubert was the corrections officer who found the girl.
He said he’d checked on her 20 minutes prior and she was sitting on her bed in her cell reading a book. Foubert said "Hi," and she looked up and smiled at him.
On the next check, when he lifted a small curtain and peaked through the window in the cell door, he spotted her hanging in the corner of the cell.
She’d climbed onto a desk in the cell and hanged herself from a bed sheet attached to the grate of a ceiling vent.
Corrections officers testified that the response was quick, and their account is backed up by footage from a camera that was pointed at the door of the cell.
Foubert can be seen calling a "Code Red" into his radio and then unlocking the cell. He said he entered the cell and lifted the girl to take pressure off her neck.
Within seconds, a second officer arrived. She said she called on the radio for a special knife used to cut objects from inmates’ necks, then helped lift the girl.
About 30 seconds after that, more staff arrived. One officer cut the girl down and staff carried her out of the cell and lay her on the floor of the common area where they removed the rest of the knotted sheet from her neck and performed CPR on her until paramedics arrived.
Paramedics, who arrived about nine minutes after the girl was found, started an IV and managed to get a pulse before they transported her out of the unit to an ambulance.
Witnesses said a defibrillator was brought in but the machine instructed staff not to shock the girl.
Corrections officers said they were surprised by the suicide. The teen was assessed as a low suicide risk, had spoken excitedly about returning to school and had plans to play hockey.
However, corrections officer Monika Daoust said that, shortly after the girl arrived at jail, she got upset because, due to jail policy, she couldn’t call a friend after she couldn’t reach her mother.
She’d also broken jail policy by trying to talk to boys housed in the unit through her cell door, and smashed a light in her cell.
On the evening she hanged herself, she and other inmates were locked in their cells due to behaviour that wasn’t specified.
The inquest is scheduled to continue throughout the week.
Briol was not the nurse who performed the girl’s intake assessment at the jail. The person who signed that document is expected to testify today.
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